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STATE OF NORTH CAROLINA <br />STATE TtLEASUR.ER'S ELECTRONIC PAYMENTS SYSTEM <br /> STEPS.liN EPT AUTHORIZATION FORM <br /> <br />(STEPS) <br /> <br />State Agency Name: <br /> <br />NORTII CAROL%HA STATE UNIVERSITY <br /> <br />Program Name: <br /> <br />Extension Payroll (Send-in Program) <br /> <br />Batch Name: <br /> <br />Check One: ........ Initial Si&nap <br /> <br />PARTICIPATING FaN I fl 'f IN'FOR. NIATION <br /> ID #: <br /> <br />. Change <br /> <br />Entity Addrm.~s: <br /> <br />FIN.-MN'CIAL INSTITUTION~ ACCT. IN'FO.: <br /> Ir~:itudo n Name: <br /> <br />Institution Addre~: <br /> <br /> Trar~ib"Routin g ~: <br /> Bank ne NCGWT Ac.~t ~ <br /> Type of Acer: Checking Savings <br /> <br />OLD FiNAI, i'ClAL INSTlq~WION ACCT. [NFO.: (Complete Only if a Change) <br /> Ins;itution Name: ....... <br /> <br /> Transit/Routln,~ #: ACC'T, ~': <br /> <br /> (Include any leading zeros) <br /> <br />.NCCMT (Chcck One) <br /> <br />PARTI~'IPATiNG FaN .t ~: f AUTHORIZATION: <br /> I-. on behalt' of the participating entity indlcatcd :bore. hereby au'thorizc thc No~h Carolina State Tre~ur~r. his succ~$ors ~nd his <br />agents, at the direction of thc State a~cnc? indicated above, to: <br /> (a) redeem shares of t~.& above dc~ignated NCCMT account and to instruct thc NCCNtT, its transfer agent, ct any of the!r :~ctus to <br /> scad thc proc=ds of such redemptions to ~ny ac:aunt designate~ by thc State Treasurer: <br /> {b~ initiate ACH debit entri,~ against the above designated bank account. <br />for moneys due the State ai:."z7 for thc referenced program name, pursuant to the 'Established Operational Procedures For Slate Tn:asurer's <br />Elcctroeic P:~ym~n~ Sys;cm.' which may be ia effect from time to time. <br /> <br />Fina,~ce Officer's Name: <br /> <br />Tel: <br /> <br />Signature: Date: -- <br /> $13~c ,Alcncy Usc Only $~te Tn:',., Use Onl?: <br /> <br />RETURN ORIGINAL WITH <br />MEMORANDUM OF AGREEMENT <br /> <br />NOTE: <br /> <br /> <br />