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36 <br />~3flicc ~f` I:he Slta.te C'oslttrofler <br />ilieluru iv: OSC NC:'~5 It:cllti 13esk <br />:1.Idr~ss :=ltl7 hlail:iCT'viC~ ~.i:ILtC:" <br />R.t:ci.h. ETC' 27G~9-1 ~t l r> <br />`L"'endor Flectruttic Payment T«rm <br />7'c:1~pil~n~: _919-K?~-1jj,- <br /> <br />For yat:r can,rcnicnce and E:•enetit, the S~:e o` tiorU: Ca'olina cffErs i~ayocs the opport:.•nit}; to receive futclre payments <br />electronica:ly. rather tan by check. Yo_r F;~,inenls ~ II be deaosited into the nc~~Cki .g or swings ~ rco4nt of yo.:r chance. <br />In aclGiGen to h2vinc the r!:tney de;~osited elec:onicaily, you also will he notified of t:.c dcpos:t either by fax or by o rn~ I_ <br />The '_~x ar e-i::3i: will pro~r'ce you ti~:i:h all th•~ infermatio- that tn~ould r:u::tta ly oe on yat:r cheek st:th. Ta rFC~i~c pay:~xnts <br />eleclroni:::~lly, y[su uiu~t p.^a. con:p•I--vte th's term, atf.~•.ch ~. voided check .,:xJ return bosh to t'+~e 2ddress aho~e. <br />¢ F*R!NT tl~o following infarmaElun. <br />Federa: ID i~ i Social ser..c:ri'y #: <br />Ba::k Nan;e: <br />Bank Ruutincd Numher: <br />n Checking f;r..count ~: <br />^ 5a;+:nps F,ccar:!~t~: <br />Re=Ttit P•c[Iress{es) fnr ~4n;,li.^.nhla.^.cc•~~nbsj: <br />G€tAN7 PAYMENTS ONLY <br />~- iFAK or E-'UfA[L AdQR1=3S for payment notification • <br />!?iace G cherk merle, ~n tr~nr of thr. method nt' no' :icatirn t-ak you ~refer_} <br />~.. ~ E•n~_iil ~~ddress: L~ =1UC:~: <br />f~u::~oriLed Signa~.~~r,: Hate:: <br />Print N:~mc: <br />~' ATl :4CFE VO1DL-Q CFiE:Cl4 <br />Title: <br />• <br />