EFT Payment Authorisation Form - Welfare.ie

An Roinn Coimirce SóisialaíDepartment of Social Protectionwww.welfare.ieFor Office use onlySupplier No:Site Name:*Only to be completed if bank account details have never been submitted or differfrom those previously submitted*EFT Payment Authorisation FormPayee Name:Payee Address:__________________________________________________________________________________________________________________________________________________________E-mail remittance address: ________________________________________Phone No:________________________Tax Registration Number/PPS Number:_____________________________I HEREBY AUTHORISE THAT ALL FUTURE PAYMENTS DUE FROM THEDEPARTMENT OF SOCIAL PROTECTION BE PAID DIRECT TO THE BANKACCOUNT DETAILED BELOWName of Account Holder:BANK ACCOUNT DETAILSName of Bank:Address of Bank Branch:Bank Branch Sort CodeBank Account NumberSigned: _________________________Authorised SignatoryName: _________________________BLOCK LETTERSPosition in Company/Org_______________________Date:______________

For Office Use onlyInputApproved