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�„yG14xY,yK,� <br /> FOR NcDA& ONLY: North Carolina Department of Agriculture <br /> Return Request to: p g <br /> Pam Winstead,supervisor and Consumer Services Terri S.Overton, <br /> Accounts Payable, NCDA&CS Director <br /> 1001 Mail Service Center Steve Troxler, Commissioner Budget&Finance <br /> Raleigh,N.C. 27699-1001 <br /> ELECTRONIC PAYMENT REQUEST FORM <br /> For your convenience and benefit, the State of North Carolina offers payees the opportunity to receive future <br /> payments electronically, rather than by check. Your payments will be deposited into the checking or savings <br /> account of your choice. In addition to having the money deposited electronically, you also will be notified of the <br /> deposit electronically, either by fax or by e-mail. The fax or e-mail will provide you with all the information that <br /> would normally be on your check stub. <br /> • ATTACH A VOID CHECK,PRINT THE INFORMATION BELOW and MAIL to your Contract <br /> Administrator as identified in your cover contract document. <br /> Payee Name <br /> Federal ID#/Social Security# <br /> Bank Name <br /> Bank routing number <br /> ( }Checking account # <br /> { )Savings account # <br /> • FAX number or e-mail address for payment notification. Place a check mark in front of the method of notification <br /> you prefer. Identify the Grant Program you are participating in as requested below. <br /> ( )FAX# { _ ) _ — - ` — _ _ OR <br /> ( ) E-mail address <br /> Authorized Signature: Date: <br /> Title: <br /> ( }Phone# <br /> (ATTACH A VOID CHECK) <br /> PLEASE IDENTIFY THE GRANT PROGRAM YOU ARE <br /> PARTICIPATING IN: <br /> E-mail: Pam.Winstead @ncagr.gov <br /> 1001 Mail Service Center,Raleigh,N.C. 27699-1001 • (919)707-3030 <br /> An Equal Opportunity Affirmative Action Employer <br />