ACT Enrollment and Direct Deposit Authorization Ohio Bureau of Workers' Compensation Attn. Benefits Payable P.O. Box 15429 Columbus, Ohio 43215-0429 Instructions Attach a voided check or personal deposit slip containing the banking information and account number to your completed ACT Enrollment and Direct Deposit Authorization. We must have either a voided check or savings deposit slip to process your ACT (automatic compensation transfer) request. Recipient/Payee Payee (first name, middle initial, last name) Social Security number Claim number(s) Account Information Financial institution name City State ZIP code Routing transit or American Banking Association number Account number Account type (checking or savings) Account holder name I authorize BWC to begin direct deposit of my workers’ compensation benefit payment(s) as indicated. I also authorize withdrawal of any funds deposited in error. This authorization will remain in full force and effect until BWC has received updated account information from me. I also agree that I will maintain current banking information. If I do not maintain current banking information, the BWC will issue me an EBT card to receive my workers’ compensation benefit payments. I agree under the terms of this agreement that deposit of my compensation payment(s) constitutes payment to me under the provisions of the Ohio Revised Code Section 4123.67. By signing this authorization, I agree that I am entitled to these benefits and will promptly notify BWC should I become employed or otherwise ineligible to receive such benefits. If you are receiving Death Widow Benefits and have remarried please contact BWC immediately and the claim will be reviewed to determine the lump sum award to which you may be entitled. Warning: I understand that any person, who obtains compensation from BWC or self-insuring employers by knowingly misrepresenting or concealing facts, making false statements or accepting compensation to which he/she is not entitled, is subject to felony criminal prosecution for fraud. By signing below, I certify I have read and understand the statements above and agree with these conditions. Recipient signature Date Day time telephone number ( BWC-0019 (9/21/2010) A-12 ) American LegalNet, Inc. www.FormsWorkFlow.com