VBIF Direct Deposit Form 1224

Virginia Birth-Related Neurological Injury Compensation Program Authorization Agreement For Automatic Payments (ACH Credits)
Instructions:

1. Complete the fill-in-the-blank and text boxes below to submit your request for Direct Deposit.

2. At the bottom of the form, upload an image of your voided check in either PDF or JPG as a photo image formats only.
This is a fill in the add your name hereby authorizes Virginia Birth-Related Neurological Injury Compensation Program, hereinafter called COMPANY, to initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit entries in error to the account indicated below and the depository named below, hereinafter called DEPOSITORY, to credit and/or debit the same to such account.
DEPOSITORY NAME
BRANCH ADDRESS
CITY
STATE
ZIP
TRANSIT/ABA NO ACCOUNT NO.
This authority is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.
TYPE OF ACCOUNT: (SELECT ONE)

CheckingSavings
AUTHORIZED SIGNER ON ACCOUNT
EMAIL ADDRESS
example@example.com
TELEPHONE NUMBER
SIGNED

Clear
DATE

MonthDayYear
Date
***** ATTACH A VOIDED CHECK AND MAIL TO ****:

Please also upload a copy of your voided check in the portal below.
Virginia Birth-Related Neurological Injury Compensation Program

7501 Boulders View Drive, Suite 600

Richmond, VA 23225
Upload a copy of your voided check here.

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Virginia Birth-Related Neurological Injury Compensation Program Authorization Agreement For Automatic Payments (ACH Credits)

***** ATTACH A VOIDED CHECK AND MAIL TO ****:

* ATTACH A VOIDED CHECK AND MAIL TO :