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Little Traverse Bay Bands of Odawa Indians
Electronic Funds Transfer (EFT) Authorization

Individuals must be at least 18 years of age to enroll.

Name:(Required)

First Last

Tribal Citizen or Organization / Individual?(Required)

Tribal Citizen

Organization / Individual

Tribal ID #(Required)

Phone Number:(Required)

Email Address:(Required)

Please indicate type of request:(Required)

New

Change

Cancel

Account Type:(Required)

Checking

Savings

Financial Institution Name:(Required)

Routing Number:(Required)

Re-enter - Routing Number:(Required)

Account Number:(Required)

Re-enter - Account Number:(Required)

Last 4 digits of your Tax ID Number:(Required)

(Social Security for individuals and EIN for organizations)

*If you select checking, please attach a voided check or a copy of a check for each checking account. If you select savings, please contact your financial institution for the correct routing numbers, as it is not always the same as the number on a savings deposit slip. Deposit slips are NOT accepted. If a voided check is unavailable, LTBB is not responsible for errors. We strongly encourage that account information is typed to avoid errors in handwriting interpretation.

*Routing and Account #: Clearly print the financial institution’s 9-digit routing number. See the check sample below for location of routing number and account number.

Copy of a check or bank statement verifing checking account. (for accuracy)(Required)

Drop files here or Select files

Accepted file types: jpg, png, gif, pdf, Max. file size: 20 MB.

Copy of your Tribal ID(Required)

Drop files here or Select files

Accepted file types: jpg, png, gif, pdf, Max. file size: 20 MB.

Copy of a Voided Check and/or your State ID or Updated W9(Required)

Drop files here or Select files

Accepted file types: jpg, png, gif, pdf, Max. file size: 20 MB.

Consent(Required)

The agreement represented by this authorization remains in effect until canceled by the applicant. Your EFT transaction will continue to be deposited into your designated account until LTBB Accounts Payable is notified in writing that you wish to redesignate and/or cancel your account. It is the applicant’s responsibility to confirm receipt of their direct deposit with their financial institution. The applicant’s name must appear on the account. If any action or inaction taken by the applicant results in non-acceptance of a direct deposit by the designated financial institution, LTBB will not process a replacement check until the amount of the non-accepted deposit is returned to LTBB. Please notify LTBB Accounts Payable if your account has been closed. In the event an erroneous payment is sent to your financial institution, LTBB reserves the right to reverse the transaction through the financial institution and debit your account for an amount not to exceed the erroneous payment.


I hereby certify that I have read and understand the information contained within this authorization form. By signing this form, I authorize LTBB to deposit payments owed to the designated Financial Institution(s) and account(s) named herein.

I agree to this agreement.

I confirm I am at least 18 years of age(Required)

I confirm I am at least 18 years of age

Applicant Signature:(Required)

Your Name

• Your Name
• Your Name
• Your Name

Date:

Questions? Contact LTBB Accounts Payable at accountspayable@ltbbodawa-nsn.gov or (231) 242-1436 or (231) 242-1541.

Accounting Use Only

Form Received By:

Information Updated On:

Signed

Date:

Submit Authorization