Printable direct deposit form - Account #1. Please attach a voided check for each account here. This authorization will be in effect until the Company receives a written termination notice from myself and has a reasonable opportunity to act on it. IMPORTANT: This document must be signed by employees requesting automatic deposit of paychecks and retained on file by the employer.

 
 *Attention Payroll Contact: Employers must keep each original Employee Direct Deposit Banking Authorization form on file as long as the employee is using direct deposit, and for two years thereafter. Employers may be subject to certain federal and state direct deposit notice, authorization and record retention requirements. . Air duct calculator

May 6, 2022 · understand that the company may require at least three (3) business days’ prior notice to cancel this authorization. This sample form is provided by Simmons Bank for your convenience. Upon completion, provide to your employer, and your employer will handle setting up direct deposits.Speak with your payroll or human resources department. Usually, all you need is your account number and routing number to sign up in just a few minutes. For Social Security or other government payments go to https://godirect.gov/gpw/ to enroll. Pre-filled WaFd Bank direct deposit form for your employer.For more information about Direct Deposit, call us on 1-888-767-6738 (TTY: 1-855-887-4957) Monday through Friday from 7:30 AM to 7:45 PM Eastern time. It is easy to sign up. You can call us toll-free using the numbers shown above. If you do not want to call us to enroll, you can fill this form out and FAX it to 724-794-6633.Payroll direct deposit authorization form: Likewise employee direct deposit form, this form is also used for the employee’s paycheck to be deposited directly into his/her account. This form is used by the payroll department of a company. With the help of this form, the payroll department keeps a record of the employees who have given them ...It takes only a few minutes. Follow these simple instructions to get Vystar Direct Deposit Form ready for sending: Find the document you will need in our collection of legal templates. Open the form in our online editor. Go through the instructions to discover which data you must provide. Select the fillable fields and put the requested info.Aug 30, 2023 · Page 8 of 17 The Vendor File Form page will open where you will begin your Direct Deposit Enrollment.This Enrollment has 5 specific sections – 1. Tax ID Information, 2.Payee Information, 3. Address/Bank Information, 4.Add Authorized Representative Contact/s, and 5.Review.To track your progress, the form highlights the stage you are in …PROVIDER DIRECT DEPOSIT ENROLLMENT INSTRUCTIONS You are not eligible for Direct Deposit if you are planning to send 100% of funds deposited to your bank to another bank outside the US. You will need the following information to complete the Direct Deposit Enrollment Form: 1. The name of your Bank. 2. The Bank Routing Number 3.1 day ago · This PDF version of the Direct Deposit Authorization Form is FREE. For the free Word version of this document, visit our Direct Deposit Authorization Form page. Some of the fields on this form may not be fillable. Some fields require a signature, date, or other information that must be hand written. If you’re not familiar with fillable PDFs ...Mar 18, 2024 · To make getting started easier, we’ve listed all information you’ll need to begin direct deposit to your Capital One® account. Send this completed form to your employer or use it to have your information ready. In no time, you’ll be on your way to No Hassle Automatic Savings! o Start a new Direct Deposit o Change my existing Direct …Early Pay Day is automatic when you set up Direct Deposit. Learn more. Three easy steps. If the company or agency that pays you offers Direct Deposit, follow these three easy steps to set up Direct Deposit into your Wells Fargo account. Step 1. Use our pre-filled form. Use our Wells Fargo Mobile ® app or sign on to create your customized ...May 31, 2022 · How to Write. Step 1 – Download the TD Bank Direct Deposit Form with the button labeled “PDF” on the right. You may use a PDF program to enter the requested information on your screen or you may print it then supply the requested information. Step 2 – Read the information in Item 1. This will provide some background as to the use of ...Aug 30, 2023 · Page 8 of 17 The Vendor File Form page will open where you will begin your Direct Deposit Enrollment.This Enrollment has 5 specific sections – 1. Tax ID Information, 2.Payee Information, 3. Address/Bank Information, 4.Add Authorized Representative Contact/s, and 5.Review.To track your progress, the form highlights the stage you are in …2 days ago · There are two ways to access the form: Use the form on CIBC.com. Download the Payroll, Direct Deposit, or Pre-Authorized Payment Form (PDF, 180 KB) Opens in a new window. Fill out each field by typing in the requested information. Save the form onto your computer. You will need to print a copy in order to sign the “Customer Signature” space.A direct deposit form is used to permit a third party to deposit money into your bank account. The form is usually intended for a payee to send to the payer. Payers are …For more information about Direct Deposit, call us on 1-888-767-6738 (TTY: 1-855-887-4957) Monday through Friday from 7:30 AM to 7:45 PM Eastern time. It is easy to sign up. You can call us toll-free using the numbers shown above. If you do not want to call us to enroll, you can fill this form out and FAX it to 724-794-6633.Instructions and Help about direct deposit form template . Today we're going to learn how to fill out the paychecks direct deposit form the first thing you're going to do and this would be for a new employee or an employee who wants to make a change in the way their paycheck is currently being deposited so at the very top you're going your first middle initial or …Jun 20, 2018 · Take advantage of Employee Access® in RUN Powered by ADP® to let your employees manage their own direct deposits. *Attention Payroll Contact: Employers must keep each original Employee Direct Deposit Banking Authorization form on file as long as the employee is using direct deposit, and for two years thereafter.Direct Deposit required in order to receive ATM fee rebates for Flagship Checking. 4 Up to $20.00 in ATM fee rebates per statement period. Available for Free Active Duty Checking only. A qualifying Military Direct Deposit must post to your Free Active Duty Checking account within 180 days of account opening. If the Military Direct Deposit stops for5 days ago · Set up direct deposit in minutes. With our automated setup, enrolling in direct deposit is as easy as 1-2-3. Skip the tedious payroll forms and set up direct deposit yourself. All you need is your payroll or employee login. Your direct deposit update is seamless, secure and verified in real time. Search for your employer or payroll provider.Get a pre-filled or blank direct deposit form from Chase to deposit your paycheck into your account. Find your routing and account number, fill in your personal information and … Direct Deposit Authorization Form I hereby authorize _____ to send credit entries, as well as make adjustments and debit entries, as appropriate, to the account(s) indicated below: Account #1: Account type (select one): Checking _____ Savings _____ Name of Financial Institution: Early Pay Day is automatic when you set up Direct Deposit. Learn more. Three easy steps. If the company or agency that pays you offers Direct Deposit, follow these three easy steps to set up Direct Deposit into your Wells Fargo account. Step 1. Use our pre-filled form. Use our Wells Fargo Mobile ® app or sign on to create your customized ...Apr 20, 2021 · Deposit amount will be full net amount of pay into either your checking/savings account. If changing your account type, bank and or account number, you will receive a payroll check until new direct deposit becomes effective. Do not send a voided blank check. Send completed form to: Central Payroll Bureau, P.O. Box 2396, Annapolis, …Dec 21, 2023 · The direct deposit method of payment is mandatory for Income Support (IS) clients, unless specifically exempted, because it: Is less costly and more efficient resulting in increased savings to taxpayers in administrative costs and fewer phone calls to workers. Provides cost saving to clients (who may otherwise pay fees at cheque cashing agencies).Our Direct Deposit form allows you to select an account that you need a direct deposit form for and get a printable or savable pdf. The first step is to navigate to the accounts menu item on the left side of your screen. Then you will select Direct Deposit Form. Next you will click the Select your desired deposit account drop down menu and ...Jul 13, 2023 · This document contains both information and form fields. To read information, Navy Federal Credit Union use the Down Arrow from a form field. Direct Deposit Enrollment I hereby authorize the company named below to initiate direct deposits to the account indicated. Account Information Navy Federal Credit Union 2560-7497-4 Account No. 1PROVIDER DIRECT DEPOSIT ENROLLMENT INSTRUCTIONS You are not eligible for Direct Deposit if you are planning to send 100% of funds deposited to your bank to another bank outside the US. You will need the following information to complete the Direct Deposit Enrollment Form: 1. The name of your Bank. 2. The Bank Routing Number 3.Feb 10, 2020 · Direct Deposit, it’s conveniently and automatically done for you. 3 2 1 Direct Deposit... FORM118021-0406 The quickest way to sign up for direct deposit – or change it – is to ask your employer for their direct deposit form, then fill it out using your new account number and routing number (see illustration below). YouTo view or print a direct deposit payroll form: From the app’s home screen, select your chequing account. Select Manage. Select Direct deposit/void cheque info. Select Direct deposit/payroll form. Select …Aug 25, 2023 · Print and fill out by hand. Standard print PDF (t3-dd-23e.pdf) Ask for an alternate format. You can order alternate formats such as digital audio, electronic text, braille, and large print. Order alternate formats for persons with disabilitiesDirect Deposit Authorization Form. Print and present this form to your Human Resources Department for processing. Member First Name Member Last Name. Enter member's name as it appears on the account. WEOKIE Account Number. WEOKIE Routing Number. Do Not Fill This Out. Print and present this banking form to your Human …Dec 13, 2023 · Download a free direct deposit authorization form in PDF or Word to let an employee give permission to an employer to deposit money into their bank account. Learn how to add an employee to your payroll and what to include on the form. 6 days ago · Speak with your payroll or human resources department. Usually, all you need is your account number and routing number to sign up in just a few minutes. For Social Security or other government payments go to https://godirect.gov/gpw/ to enroll. Pre-filled WaFd Bank direct deposit form for your employer.2 days ago · Direct Deposit Form. Enroll in direct deposit or make changes such as removing bank accounts, adjusting the amounts deposited between them and a payroll debit card, and more. Form in Spanish. Download Direct Deposit Form.Step 1 – Download The NetSpend Direct Deposit Enrollment Form from the PDF button below the image on the right side of this page. It is recommended to save a copy for your records, thus you may either fill this form out onscreen using a PDF editor then print two copies or Print the form and copy it once you have filled it out. Step 2 – …Feb 10, 2020 · Direct Deposit, it’s conveniently and automatically done for you. 3 2 1 Direct Deposit... FORM118021-0406 The quickest way to sign up for direct deposit – or change it – is to ask your employer for their direct deposit form, then fill it out using your new account number and routing number (see illustration below). You6 days ago · Speak with your payroll or human resources department. Usually, all you need is your account number and routing number to sign up in just a few minutes. For Social Security or other government payments go to https://godirect.gov/gpw/ to enroll. Pre-filled WaFd Bank direct deposit form for your employer.How to Write. Step 1 – Download the TD Bank Direct Deposit Form with the button labeled “PDF” on the right. You may use a PDF program to enter the requested information on your screen or you may print it then supply the requested information. Step 2 – Read the information in Item 1. This will provide some background as to the use of ...Dec 14, 2023 · Web. To view or print a direct deposit payroll form: From your Accounts page, select your chequing account. Select Direct Deposits & Payments. Go to Direct Deposit / Payroll Form and select View/Print. You can also view and print a void cheque. To see a demo of this feature, visit our Digital Banking Guides. Last updated December 14, …Apr 17, 2024 · You work hard – setting up direct deposit shouldn’t also feel like work. Now it takes just 2 minutes to start getting your pay up to 2 days early * * Early direct deposit availability depends on payor type, timing, payment instructions, and bank fraud prevention measures. As such, early direct deposit availability may vary from pay period to pay period.Financial Institution. I hereby authorize __________ [Employer Name] to deposit all payments due to me into the account(s) listed above. In addition, I grant __________ …Direct Deposit Authorization Form. Print and present this form to your Human Resources Department for processing. Member First Name Member Last Name. Enter member's name as it appears on the account. WEOKIE Account Number. WEOKIE Routing Number. Do Not Fill This Out. Print and present this banking form to your Human …May 31, 2022 · How to Write. Step 1 – Download the TD Bank Direct Deposit Form with the button labeled “PDF” on the right. You may use a PDF program to enter the requested information on your screen or you may print it then supply the requested information. Step 2 – Read the information in Item 1. This will provide some background as to the use of ...Jun 24, 2022 · Setting up direct deposit on Online Banking. 1 Log into Online Banking. Select the account you want to use for Direct Deposit. Select “Void Cheque” from the Account Details box. Open the downloaded file. To get your government funds deposited in your account, select CRA direct deposit. Instructions and Help about direct deposit form template . Today we're going to learn how to fill out the paychecks direct deposit form the first thing you're going to do and this would be for a new employee or an employee who wants to make a change in the way their paycheck is currently being deposited so at the very top you're going your first middle initial or name and your last name right ... It takes only a few minutes. Follow these simple instructions to get Vystar Direct Deposit Form ready for sending: Find the document you will need in our collection of legal templates. Open the form in our online editor. Go through the instructions to discover which data you must provide. Select the fillable fields and put the requested info.Apr 19, 2022 · DIRECT DEPOSIT AUTHORIZATION FORM I hereby authorize _____ (company name) to send credit entries, as well as appropriate debit and adjustment entries, to my account indicated below. These deposits may be made electronically or by any other commercially accepted method. Personal information ...Download and print a fillable PDF form to authorize direct deposit of your paycheck. Enter your name, address, bank information, amount and signature, and attach a voided …The second step in direct deposit enrollment is to ask your employer for direct deposit forms. These are generally very basic. It helps to have your Social Security number handy, and a blank check or account and ABA routing numbers. (see Step 3). If asked for a voided check, write VOID in ink with large letters across the check, covering most ...Download free printable direct deposit authorization forms in MS Word format and learn how to fill them out. Find out how to add an employee to payroll, file …5 days ago · DIRECT DEPOSIT REQUEST FORM Complete this form, then print it, sign it and take it to your employer’s payroll department to request direct deposit of your paycheck. Customer name . Address . City. State. ZIP code. Please have my paycheck automatically deposited into the following account: Checking account number . Or . … DIRECT DEPOSIT REQUEST FORM Complete this form, then print it, sign it and take it to your employer’s payroll department to request direct deposit of your paycheck. Customer name . Address . City. State. ZIP code. Please have my paycheck automatically deposited into the following account: Checking account number . Or . Savings/MIA/Money ... Sep 24, 2021 · A direct deposit authorization form is a document that authorizes an employer or third party for payment. Further, through the employer money goes into employees’ accounts. You don’t need to visit a bank and the salary comes directly into your account. Moreover, through the authorization form, you authorize the bank to take care of your ... Easily Editable, Printable, Downloadable. Here's our Direct Deposit Enrollment Form template to help you create a professionally-made form your bank can use to hand to clients who wish to avail of direct deposits. This high-quality template is ready-made and easy to use that you can create a form for your bank within minutes after download.To view or print a direct deposit payroll form: From the app’s home screen, select your chequing account. Select Manage. Select Direct deposit/void cheque info. Select Direct deposit/payroll form. Select …Oct 12, 2023 · In receiving the money, the employee must fill out and submit a Direct Deposit Form to the employer. The Direct Deposit Form will require the employee to fill in essential information such as name of the bank, account type, account number, and the bank’s routing number. The employee only needs to keep track of his account through …Download or create a direct deposit form for payroll purposes. Learn what information to provide and how to complete the form with a voided check or deposit slip.Download a free direct deposit authorization form in PDF or Word to let an employee give permission to an employer to deposit money into their bank account. Learn how to add an employee to your …Apr 20, 2022 · Direct Deposit. Complete this form and give it to your employer / payer. If they prefer to use their own form, you can use this as a reference. (company name) to initiate deposits and, if necessary, withdrawals to correct erroneous deposit entries to my account(s) listed above. I understand that this authorization replaces any previous ...Sep 26, 2023 · Step 1: Choose a Direct Deposit Provider. The two most common ways to set up direct deposit are through your bank and with your payroll software. Many payroll software offer this function and can automatically process payroll as direct deposits. There are also some HR services and software with payroll capabilities that can provide direct ...Dec 19, 2023 · If you’re asked to do this, write “VOID” across the front of a blank check, which ensures the check’s unusable if it’s lost or stolen. Then attach the check or slip to the direct deposit ...Jun 1, 2022 · Virginia. Create Document. Updated June 01, 2022. The Paychex direct deposit form must be filled out and signed by an employee wishing to set up a direct deposit transfer as a method of compensation with their employer. This form should then be submitted by the employer to the Paychex office where they hold a payroll account.How to Write. Step 1 – Download the TD Bank Direct Deposit Form with the button labeled “PDF” on the right. You may use a PDF program to enter the requested information on your screen or you may print it then supply the requested information. Step 2 – Read the information in Item 1. This will provide some background as to the use of ...Jan 18, 2022 · Direct deposit form is used to receive your payroll or other deposits to your account. Pre-authorised payment using void cheque is used to automatically pay ... Apr 17, 2024 · * When on a desktop, hover over * to view important disclosures. When on a mobile device, click on * to view disclosures. Online access, mobile number verification (via text message) and identity verification (including SSN) are …2 days ago · Direct Deposit Form. Enroll in direct deposit or make changes such as removing bank accounts, adjusting the amounts deposited between them and a payroll debit card, and more. Form in Spanish. Download Direct Deposit Form.A Direct Deposit Authorization Form is a document that a recipient, often an employee, uses to grant a payor, typically an employer, permission to electronically transfer funds into a bank account.Apr 23, 2019 · This direct deposit form for new hires created by Betterteam. Direct Deposit Authorization Form By completing this form, you consent for [company name] to deposit your wages, minus applicable taxes, directly into your bank account on a week/bi-weekly/monthly basis. This form is not valid without the signature of the accountholder. Name (please ... The first direct deposit will be made approximately 3 months after receipt of your completed enrolment form. To update your banking information, please complete a new direct deposit enrolment form. Please do not use this form to provide change of address information. Please read the privacy notice. All fields identified as (required) must be ...6 days ago · If you're using Adobe Reader, the form will open in a new window. If you don't already have a pdf viewer installed on your computer, download Adobe Reader. The bank account information you'll need includes your name; transit number (up to 5 digits); account number (up to 7 digits); branch number, which is the first 4 digits of the transit number …Aug 25, 2023 · Print and fill out by hand. Standard print PDF (t3-dd-23e.pdf) Ask for an alternate format. You can order alternate formats such as digital audio, electronic text, braille, and large print. Order alternate formats for persons with disabilities For additional information or for assistance, you may: consult the Canada direct deposit enrolment form completion instructions; consult with your financial institution; call 1‑800‑593‑1666 toll free Monday, Tuesday, Wednesday and Saturday from 7 am to 7 pm or Thursday and Friday from 7 am to 10 pm, eastern standard time. To enroll in Full Service Direct Deposit, simply fill out this form and give it to your payroll manager. Attach a voided check for each checking account – not a deposit slip. If depositing to a savings account, ask your bank to give you the Routing/Transit Number for your account. It isn’t always the same as the number on a savings deposit ...01. Start by obtaining the ADP Direct Deposit Form from your employer or the ADP website. 02. Fill in your personal information, such as your full name, address, and contact details, in the designated fields. 03. Provide your banking information, including the name of your bank, routing number, and account number.Jan 4, 2022 · Simply login to your online banking, click on the account that you wish to have your money deposited into and select the print payroll direct deposit form. These instructions may vary slightly from bank-to-bank, but should remain relatively similar regardless of Institution. Once printed, all you need to do is sign your direct deposit form … Order foreign currency in cash, by bank draft, or set up a wire transfer by visiting us at a branch, or by calling us at 1-888-826-2489 for more information. Businesses can work with our Foreign Exchange Account Managers, who offer a wide variety of services to help you reduce costs and manage risk. Set up Vancity direct deposits to skip the ... 2. Government Benefits Direct Deposit Authorization Form: This form is used to authorize the deposit of government benefits like Social Security, Veterans Affairs benefits, tax refunds, or unemployment benefits. Recipients of these benefits must provide similar banking information to the appropriate government agency. 3. Financial Institution. I hereby authorize __________ [Employer Name] to deposit all payments due to me into the account(s) listed above. In addition, I grant __________ [Employer Name] the authority to take any corrective actions, including debits, as needed, in relation to these deposits. This authorization will remain in effect until I ... 2 days ago · There are two ways to access the form: Use the form on CIBC.com. Download the Payroll, Direct Deposit, or Pre-Authorized Payment Form (PDF, 180 KB) Opens in a new window. Fill out each field by typing in the requested information. Save the form onto your computer. You will need to print a copy in order to sign the “Customer Signature” space.Oct 19, 2021 · Complete this form to request direct deposit into your KeyBank checking or savings account. 3 Easy Steps! Fill-in this form online or print it off and fill it out. Attach a voided check to this form to confirm your account and routing numbers. 3. Submit this completed form and a voided check to the appropriate department:Aug 30, 2023 · Page 8 of 17 The Vendor File Form page will open where you will begin your Direct Deposit Enrollment.This Enrollment has 5 specific sections – 1. Tax ID Information, 2.Payee Information, 3. Address/Bank Information, 4.Add Authorized Representative Contact/s, and 5.Review.To track your progress, the form highlights the stage you are in …Find 44 free templates for direct deposit authorization forms to securely and conveniently receive your salary or wages directly into your bank account. Learn how to create, use, …

Updated May 31, 2022. The Navy Federal Credit Union (NFCU) direct deposit authorization form is a standard form which requires the basic information necessary to set up electronic fund transfers with an Employer and the Navy Federal Credit Union. This form should be submitted to your employer provided they will accept and process it with the intention of …. Van nuys los angeles

printable direct deposit form

DIRECT DEPOSIT REQUEST FORM Complete this form, then print it, sign it and take it to your employer’s payroll department to request direct deposit of your paycheck. Customer name . Address . City. State. ZIP code. Please have my paycheck automatically deposited into the following account: Checking account number . Or . Savings/MIA/Money ... Digital Banking. Our advanced online and mobile banking platform was designed with you in mind, allowing you to bank anywhere, anytime. With features that let you easily transfer funds, make payments, and even deposit checks, our Digital Banking is streamlined for today's on-the-go world. Learn More. *The timing of your pay being posted to the ...Sep 26, 2023 · Step 1: Choose a Direct Deposit Provider. The two most common ways to set up direct deposit are through your bank and with your payroll software. Many payroll software offer this function and can automatically process payroll as direct deposits. There are also some HR services and software with payroll capabilities that can provide direct ...The second step in direct deposit enrollment is to ask your employer for direct deposit forms. These are generally very basic. It helps to have your Social Security number handy, and a blank check or account and ABA routing numbers. (see Step 3). If asked for a voided check, write VOID in ink with large letters across the check, covering most ...It takes only a few minutes. Follow these simple instructions to get Vystar Direct Deposit Form ready for sending: Find the document you will need in our collection of legal templates. Open the form in our online editor. Go through the instructions to discover which data you must provide. Select the fillable fields and put the requested info.Apr 19, 2022 · DIRECT DEPOSIT AUTHORIZATION FORM I hereby authorize _____ (company name) to send credit entries, as well as appropriate debit and adjustment entries, to my account indicated below. These deposits may be made electronically or by any other commercially accepted method. Personal information ... Instructions and Help about direct deposit form template . Today we're going to learn how to fill out the paychecks direct deposit form the first thing you're going to do and this would be for a new employee or an employee who wants to make a change in the way their paycheck is currently being deposited so at the very top you're going your first middle initial or name and your last name right ... Nov 10, 2022 · 2.Payroll Compensation. Complete and sign this direct deposit form and give it to your employer’s payroll representative – it’s that easy! Employee name and address: Employee phone number: Employee ID: (if applicable) Employee social security number: Please begin directly depositing my payroll and/or dividend or annuity check into my ... Collection of the information in this Direct Deposit Sign-Up Form is authorized by 5 U.S.C. § 552a, 31 U.S.C. § 3332(g), and Executive Order 9397 (November 22, 1943). Your social security number and the other information requested will allow the Federal Government to process your direct deposit. Your social security number is requested to ... please print clearly in black/blue ink only I wish to deposit (check one): _____% of Net Specific Dollar Amount $ _____________ .00 Remainder of Net Pay I confirm that the above named employee/worker has added or changed a bank account for direct deposit transactions processed by Collection of the information in this Direct Deposit Sign-Up Form is authorized by 5 U.S.C. § 552a, 31 U.S.C. § 3332(g), and Executive Order 9397 (November 22, 1943). Your social security number and the other information requested will allow the Federal Government to process your direct deposit. Your social security number is requested to ...Mar 14, 2024 · By mail. Fill out Form T3-DD, Direct Deposit Request for T3. Mail the completed form to the address on the form. For more information about direct deposit for trusts, call 1-800-959-8281. To start direct deposit or to change your banking information related to direct deposit the following must apply: you are a Canadian payer or agent.If you have questions or need help understanding how to set up or change direct deposit online, call our toll-free number at 1-800-772-1213 or visit your Social Security office. If you are deaf or hard of hearing, call our toll-free TTY number, 1-800-325-0778 , between 8:00 a.m. and 5:30 p.m. Monday through Friday.For more information about Direct Deposit, call us on 1-888-767-6738 (TTY: 1-855-887-4957) Monday through Friday from 7:30 AM to 7:45 PM Eastern time. It is easy to sign up. You can call us toll-free using the numbers shown above. If you do not want to call us to enroll, you can fill this form out and FAX it to 724-794-6633..

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