Verification of Deposit - Medical or Public Assistance Agencies - Fax Request To Balance Confirmation Services

Sep 17, 2026

Uploaded by Dipper

Verification of Deposit form for medical or public assistance agencies requesting consumer deposit information. The requester completes Section 1 with agency details and contact information, then Section 2 with customer identity and account data. Instructions require typing or completing in black ink using capital letters, adding the customer authorization signature, and faxing the completed request to the provided number for return via the fax number listed on the form.

LanguageEnglish

CategoryForms

FormatPDF

Pages1

AccessFree to download

Verification of Deposit - Medical or Public Assistance Agencies

Requester information

Customer information

Customer authorization

Verification of Deposit Medical or Public Assistance Agencies For faster processing, please complete the form on your computer before printing. This form is for medical or public assistance agencies requesting consumer deposit information. Please complete the form including the customer authorization signature and fax to the number below. Your completed request will be faxed to the return fax number provided on this form. TYPE or complete in BLACK INK. Use only CAPITAL LETTERS Fax Request To Balance Confirmation Services........................................................................................................1-844-879-0412 Online [Instructions............................................................................................................................](Instructions.......................................................................................................................................www.wellsfargo.com/vod)[........](Instructions.......................................................................................................................................www.wellsfargo.com/vod)[...www.wellsfargo.com/vod](Instructions.......................................................................................................................................www.wellsfargo.com/vod) SECTION 1 : REQUESTER INFORMATION | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | Company Name | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | Attention | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | City State Zip | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | Requester Email (optional) | | | | | --- | --- | --- | - | | | | | --- | --- | --- | - | | | | | | --- | --- | --- | --- | | | | | | --- | --- | --- | - | | | | | --- | --- | --- | - | | | | | | --- | --- | --- | --- | Requester Phone Number Return Fax Number SECTION 2: CUSTOMER INFORMATION | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | Customer One Full Name ( First Middle Last) | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | Customer Two Full Name (First Middle Last) | | | | | --- | --- | --- | - | | | | --- | --- | - | | | | | | --- | --- | --- | --- | Customer One Social Security Number Account Number(s) | | | | | | | | | | | | | | | | | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | | | | | | | | | | | | | | | | | CUSTOMER AUTHORIZATION I/We authorize and direct Wells Fargo Bank to release the following

FAQs

Who should complete this form and what is it used for?

Medical or public assistance agencies use the form to request consumer deposit information for faster verification and processing.

What information is required in Section 1?

Section 1 collects requester (agency) details such as company name, attention line, city/state/zip, optional requester email, and contact details including phone and return fax number.

What must be included in Section 2 and how is the form submitted?

Section 2 gathers customer identity and deposit account details, and the customer authorization section must be signed and dated. The completed request is faxed to the number listed on the form for return to the provided return fax number.

Sep 17, 2026

Uploaded by Dipper