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600 Technology Center Drive, Stoughton, MA 02072 Toll Free Phone #: 1-877-479-7577 Toll Free Fax #: 1-800-359-2884 Rev. 04/2017

This document is a direct deposit application for PCA Dorian G. Gailliard to receive payment deposits into their Wells Fargo bank account. It provides the PCA and consumer's contact information, the bank account number and routing number, and a signature from the PCA authorizing Tempus Unlimited to deposit funds into the account. The PCA must provide documentation like a voided check to verify the bank account information.

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Dorian Gailliard
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373 views1 page

600 Technology Center Drive, Stoughton, MA 02072 Toll Free Phone #: 1-877-479-7577 Toll Free Fax #: 1-800-359-2884 Rev. 04/2017

This document is a direct deposit application for PCA Dorian G. Gailliard to receive payment deposits into their Wells Fargo bank account. It provides the PCA and consumer's contact information, the bank account number and routing number, and a signature from the PCA authorizing Tempus Unlimited to deposit funds into the account. The PCA must provide documentation like a voided check to verify the bank account information.

Uploaded by

Dorian Gailliard
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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BYIHVPBTIQ

DIRECT DEPOSIT APPLICATION


Dorian G. Gailliard
PCA’S Name: ____________________________________ PCA Phone Number: (617) 276-7989
______________________

6258
Consumer #: _______________ David Drayton
Consumer’s Name: ___________________________________________
Account Information

Dorian Gailliard
Name on Bank Account: ________________________________________________________________________
(PER MASSHEALTH - Direct Deposit Accounts must be in the name of the PCA only, the account cannot be a
joint account shared by the PCA and the Consumer or the surrogate. )

Wells Fargo Bank, N.A.


Bank Name: __________________________________________________________________________________

121000248
Bank Routing #: ________________________________ 22119719206864374
Bank Account #: __________________________

This is a Checking Account Savings Account

For a checking account please attach a voided check or a copy of a check (Starter checks must contain a preprinted PCA
name and account number). For a savings account please attach a document from the bank indicating the PCA’s name,
the routing number and account number (cannot be handwritten). Do not attach a deposit slip. We will not process this
application without a voided check, a copy of a check, or a document from your bank indicating the routing number and
account number.

John Doe 1000


123 Main Street
Quincy, MA 02169

I hereby authorize T e mp u s U n l i m i t e d , I n c . (hereinafter "Company'') to deposit any amounts owed to me by


initiating credit entries to my account at the financial institution (hereinafter "Bank") indicated on this form. Further,
I authorize the Bank to accept and to credit any credit entries indicated by the Company to my account. In the event
that the Company deposits funds erroneously into my account, I authorize the Company to debit my account for an
amount not to exceed the original amount of the erroneous credit. This authorization is to remain in full force and effect
until the Company and the Bank have received written notice from me of its termination in such time and in such
manner as to afford the Company and the Bank reasonable opportunity to act on it.

04/22/2020
PCA’s Signature: ________________________________________________ Date: _________________________
600 Technology Center Drive, Stoughton, MA 02072 www.tempusunlimited.org
Toll Free Phone #: 1-877-479-7577 Toll Free Fax #: 1-800-359-2884
Rev. 04/2017
Doc ID: 85f2f17af3745e7c5b969c3c0e47d78962374df7

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