[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-306334-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-306334-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","commonwealth-of-pennsylvania-liheap-electronic-funds-transfer-application-form","Commonwealth of Pennsylvania - LIHEAP Electronic Funds Transfer Application Form","","This document serves as the official Electronic Funds Transfer (EFT) application form for the Low-Income Home Energy Assistance Program (LIHEAP) administered by the Commonwealth of Pennsylvania Department of Public Welfare. The form is designed for vendors to authorize the direct deposit of program payments into their financial accounts. It requires essential business and banking details, including vendor identification, FEIN, ABA routing numbers, and specific bank account information. The application also includes sections for authorizing the start, cancellation, or modification of EFT services, and provides a clear mechanism for requesting payment via check should an electronic transmission fail. Compliance with instructions, such as attaching a voided check, is mandatory for successful processing. The form ensures that the state maintains accurate financial records for energy assistance disbursements, necessitating an authorized signature to certify the validity of the provided information. 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This application cannot be processed if submitted without a voided check.  \nVendor Name   Legal Entity   Vendor’s Financial Coordinator   FEIN Number    \nTelephone Number   LIHEAP Vendor Number(s)    \n(13 digits)  \nThe Name of the Bank Receiving the Deposit   ABA Transit Routing Number    \nVendor’s Bank Account Number    \nType of Authorization:   Start   Cancellation   Change  \nType of Account:   Checking   Savings  \nI hereby authorize the Commonwealth of Pennsylvania to post payments into the financial account referenced above. I understand that I am responsible for the validity of the information on this form. If the EFT transmission fails, I would like payment by check to be mailed to the address below:  \nCompany Name    \nStreet    \nCity and State   Zip Code   County    \nVendor’s Signature or  \nSignature of Authorized Officer of Vendor  \nDate  \nMAIL APPLICATIONS TO: LIHEAP  \nP.O. Box 2675  \nHarrisburg, PA 17105 Attention: Vendor Unit","cbCaikjyWklvdwZT","https://ap.wps.com/l/cbCaikjyWklvdwZT","pdf",84110,"English","# Vendor and Financial Information\n## Banking and Authorization Details\n## Company Contact and Mailing Information","[{\"question\":\"What is the purpose of this application form?\",\"answer\":\"This form allows LIHEAP vendors to authorize the Commonwealth of Pennsylvania to deposit program payments directly into their financial accounts via Electronic Funds Transfer (EFT).\"},{\"question\":\"What documentation must be attached to the application for it to be processed?\",\"answer\":\"You must attach a voided check to the application. The document explicitly states that it cannot be processed without one.\"},{\"question\":\"What types of authorizations can a vendor request on this form?\",\"answer\":\"Vendors can request to start, cancel, or change their Electronic Funds Transfer authorization using this form.\"}]","Commonwealth of Pennsylvania - LIHEAP Electronic Funds Transfer Application Form | PDF",1789835463]