New Jersey Department of Health

WIC Services

P.O. Box 364

Trenton, NJ 08625-0364	AUTHORIZATION AGREEMENT FOR

DIRECT DEPOSIT (ACH) CREDITS

Stamp Number:
Store Name:
Address:
City, State:
Zip Code:

Please verify your routing and account numbers with your bank or corporate office before completing this section. IMPORTANT: If any of this information changes, immediately notify New Jersey WIC Services, by calling a State Agency Vendor Unit representative at (609) 292-9560 or submit by fax at (609) 633-2794.

Depository Bank Name:
Branch:
Address:
City, State:
Zip Code:
Telephone Number:
Routing (Transit) Number:
Checking Account Number:

I (We) hereby authorize New Jersey WIC Services to initiate credit entries to my (our) bank account. These credit transactions should be made to the depository bank named above. If funds to which I am not entitled are deposited to my account, I (we) authorize New Jersey WIC Services to direct the financial institution(s) to return said funds.

Name of Vendor Authorized Person (Print)

Title

Signature	Date

Attach a copy of a blank VOIDED check from your account to ensure that your ACH credit is correctly applied.

The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and, where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or if all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.)

If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html. or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov.

Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339 or (800) 845-6136 (Spanish).

USDA is an equal opportunity provider and employer.

WIC-21

JUN 15

WIC-21, Authorization Agreement for Direct Deposit (ACH) Credits

WIC-21, Authorization Agreement, Direct Deposit, ACH, Direct Deposit Credits, WIC Services, WIC

Ewhite

2015-06-19

NJDOH