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  • DEPARTMENT OF SOCIAL SERVICES VENDOR DIRECT …...will continue to be issued by this method until a new direct-deposit authorization form is submitted to DSS with correct information
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DEPARTMENT OF SOCIAL SERVICES VENDOR DIRECT DEPOSIT FORM Submit to: Department of Social Services Benefits Accounting 55 Farmington Ave 12 th Floor Hartford, CT 06105 Fax 860-424-4962 VENDOR INFORMATION Vendor FEIN/SS (Please Include IRS W-9 Form) _______________________________________________________ Vendor/Business Name __________________________________________________ DBA NAME __________________________________________________ Vendor Contact Name __________________________________________________ Email __________________________________________________ Telephone __________________________________________________ Address __________________________________________________ Vendor City, State, Zip code _________________________________________________ VENDOR BANK INFORMATION Direct Deposit Vendor Bank Name _______________________________________________ Vendor Bank Account Type (Checking or Savings) _______________________________________________ Vendor Bank Account Number _______________________________________________ Vendor Bank Routing and Transit Number _______________________________________________ I understand I am responsible for the validity of the information stated above. I hereby authorize the Connecticut Department of Social Services (DSS) to initiate electronic deposits to the bank account specified on this form. I further authorize DSS to initiate debit entries as adjustments for credit entries made in error. In the event that, for any reason, the bank is unable to return funds deposited in error to DSS, I hereby authorize DSS to recover those funds by deducting the amount of said funds from any future payments. I understand that DSS may alternatively request return of said funds in writing, and agree to return said funds within two (2) weeks of receipt of such a request. I further agree that if such funds are not repaid to DSS, I will be liable for all costs of collection. I understand that this direct-deposit authorization will remain in full force and effect until DSS receives written notification from me or an authorized officer of my organization of its termination. Such notification must be provided in such a time and manner as to afford DSS a reasonable opportunity to act upon it. Neither DSS nor the State of Connecticut will be responsible for any mistaken, fraudulent or erroneous information provided on this form Please list the name of the individual authorized to complete this form Name________________________________________________ Phone Number _______________________________ Signature___________________________________________________________Date___________________________ Title ________________________________________________ Phone number ________________________________ NEW ENROLLEE CHANGE OF FINANCIAL INSTITUTION OR ACCOUNT DISCONTINUE DIRECT DEPOSIT Persons who are deaf or hard of hearing and have a TTD/TTY device can contact DSS at 1-800-842-4524. Persons who are blind or visually impaired, can contact DSS at 1-860-424-5040.

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  • DEPARTMENTOFSOCIALSERVICESVENDORDIRECTDEPOSITFORM

    Submitto:DepartmentofSocialServicesBenefitsAccounting55FarmingtonAve 12thFloor ` Hartford,CT06105Fax860-424-4962

    VENDORINFORMATION

    VendorFEIN/SS(PleaseIncludeIRSW-9Form) _______________________________________________________

    Vendor/BusinessName __________________________________________________

    DBANAME __________________________________________________

    VendorContactName __________________________________________________

    Email __________________________________________________

    Telephone __________________________________________________

    Address __________________________________________________

    VendorCity,State,Zipcode _________________________________________________

    VENDORBANKINFORMATION Direct Deposit

    VendorBankName_______________________________________________

    VendorBankAccountType(CheckingorSavings)_______________________________________________

    VendorBankAccountNumber _______________________________________________

    VendorBankRoutingandTransitNumber_______________________________________________

    IunderstandIamresponsibleforthevalidityoftheinformationstatedabove.IherebyauthorizetheConnecticutDepartmentofSocialServices(DSS)toinitiateelectronicdepositstothebankaccountspecifiedonthisform.IfurtherauthorizeDSStoinitiatedebitentriesasadjustmentsforcreditentriesmadeinerror.Intheeventthat,foranyreason,thebankisunabletoreturnfundsdepositedinerrortoDSS,IherebyauthorizeDSStorecoverthosefundsbydeductingtheamountofsaidfundsfromanyfuturepayments.IunderstandthatDSSmayalternativelyrequestreturnofsaidfundsinwriting,andagreetoreturnsaidfundswithintwo(2)weeksofreceiptofsucharequest.IfurtheragreethatifsuchfundsarenotrepaidtoDSS,Iwillbeliableforallcostsofcollection.Iunderstandthatthisdirect-depositauthorizationwillremaininfullforceandeffectuntilDSSreceiveswrittennotificationfrommeoranauthorizedofficerofmyorganizationofitstermination.SuchnotificationmustbeprovidedinsuchatimeandmannerastoaffordDSSareasonableopportunitytoactuponit.NeitherDSSnortheStateofConnecticutwillberesponsibleforanymistaken,fraudulentorerroneousinformationprovidedonthisform

    Pleaselistthenameoftheindividualauthorizedtocompletethisform

    Name________________________________________________PhoneNumber_______________________________

    Signature___________________________________________________________Date___________________________

    Title________________________________________________Phonenumber________________________________

    NEWENROLLEE

    CHANGEOFFINANCIALINSTITUTIONORACCOUNT

    DISCONTINUEDIRECTDEPOSIT

    Persons who are deaf or hard of hearing and have a TTD/TTY device can contact DSS at 1-800-842-4524. Persons who are blind or visually impaired, can contact DSS at 1-860-424-5040.

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    delabruererTypewritten TextSTATE OF CONNECTICUT

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    delabruererTypewritten TextW-260 (New 3/18)

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  • PleaseprovideacompletedIRSFormW-9(RequestforTaxpayerIdentificationNumberandCertification).ThisisafederalformthatcertifiestheTaxpayerIdentificationNumber(FederalEmployerIdentificationNumberorSocialsecurityNumber).Youmayaccessafillableversionoftheformat:www.irs.gov/pub/irs-pdf/fw9.pdf

    Toverifyaccuracyofbankinformation,pleaseincludeacopyofavoidedcheckorsomeotherdocumentationthatincludesyourbankinformation.Foraccountsfromwhichyoudonotwritechecks,pleaseincludealetterfromyourbankshowingtheAmericanBankersAssociationroutingnumber,accountnumber,andthename(s)ontheaccount.

    Keepacopyofthisvendordirectdepositformforyourrecords.YoumustinformDSSBenefitsAccountingofanychanges.Ifyouchangefinancialinstitutionsoraccounts,youareobligatedtonotifyDSSofthesechanges.Todoso,pleaseresubmitthisformwithupdatedinformationassoonaspossibletoavoiddelayedreceiptofyourpayment.AlteredFormswillnotbeaccepted.

    Whenfundsarerejectedorreturnedbythebank,paymentswillrevertbacktocheckwithoutnoticetothevendorandwillcontinuetobeissuedbythismethoduntilanewdirect-depositauthorizationformissubmittedtoDSSwithcorrectinformation.

    Complete,signandreturnthisformtoDSSbyoneofthefollowingmethods:

    Byfaxto860-424-4962

    Bymailto:DepartmentofSocialServicesBenefits Accounting 55FarmingtonAve.,12thfloorHartford,CT06105Fax 860-424-4962

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    delabruererTypewritten TextINSTRUCTIONS FOR COMPLETING THE W-260 VENDOR DIRECT DEPOSIT FORM

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    Phone Number: Date: Title: Phone number: Vendor FEIN/SS: 0:

    Vendor /Business Name: DBA Name: Vendor Contact Name: Email: Telephone: Address: Vendor City, State, Zip code: Vendor Bank Name: 0:

    Vendor Bank Account Type: Vendor Bank Number: Vendor Bank Routing and Transit Number: Name: New: OffChange: OffDiscontinue: Off


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