STATE OF WYOMING WOLFS-109b Vendor Changes* The State of Wyoming must have a properly completed form before payment will be made. PLEASE RETURN THIS FORM TO STATE AGENCY CONTACT INFORMATION FOUND IN BOX TO THE RIGHT STATE AGENCY CONTACT INFORMATION Agency #, Agency Name, Contact Name, Title, Address; Phone # Save a Tree Choose EFT **If you have changed your EIN number or you have a new business name, please complete a new WOLFS109(a) vendor form. PART 1: Vendor Information VENDOR NUMBER from the VCUST2 Table: (State Agency fills this in) VENDOR NAME: (State Agency fills this in) Doing Business As (DBA), if applicable: (Vendor fills this in) (Check appropriate box below then enter FEIN or SSN in boxes to the right.) Federal Employer Identification Number (FEIN): Social Security Number (SSN): OR Enter TIN HERE (FEIN or SSN)-- Do Not Use Dashes (Vendor fills this in) Note: Federal Tax ID or SSN must be the correct number for the tax reporting name. Part 2: Vendor Changes PROVIDE ONLY NEW INFORMATION Changes to an existing vendor only ­ Check and complete only the applicable box(es): DISCONTINUE Existing Vendor File Record INDIVIDUAL NAME CHANGE**: Note: Individuals changing a name (as in the case of marriage or divorce) must notify both Social Security and IRS prior to submitting this form to the State agency. Note: "Business" name changes must be submitted on a WOLFS-109A Vendor form. DBA NAME CHANGE: ADDRESS CHANGE: Address: City: State: Zip ESTABLISH A NEW DIRECT DEPOSIT AUTHORIZATION: I authorize electronic fund transfer (EFT) payment into my checking account by attaching with the current information either a copy of a voided check from my checking account or a certified letter from my financial institution or a vendor payment direct deposit (EFT) bank certification form (see page 2) Attached with the current information is a copy of either a voided check from my checking account with the current information, or a certified letter from my financial institution or a vendor payment direct deposit (EFT) bank certification form (see page 2). CHANGE MY CURRENT BANKING INFORMATION: UPDATE SAVINGS ACCOUNT INFORMATION: A certified letter from my financial institution or a vendor payment direct deposit (EFT) bank certification form (see page 2), has been attached with the Account Type (i.e. checking or savings) identified, the ABA routing number, and account number provided. I understand by choosing this option, I will receive my payments via check in the mail, at the address on the vendor file. DISCONTINUE DIRECT DEPOSIT AUTHORIZATION: Part 3: Certification I certify the above information is accurate as of the date set out by me on this form. I am responsible for updating and maintaining my information whenever this information changes. SIGNATURE: Save a Tree Choose EFT DATE: American LegalNet, Inc. www.FormsWorkFlow.com PRINTED NAME: Form Revised 5/16/2014 State of Wyoming State Auditor's Office Vendor Payment Direct Deposit (EFT) Bank Certification Please fill in the following information to allow vendor payments to be processed by EFT (direct deposit). All fields are required if you are using this form. Only fill out this form if you do not have a copy of a voided check. Save a Tree Choose EFT Part 1: Vendor Information (Vendor fills this in this section) Vendor Name: Vendor Address: City: Vendor Phone Number: State: Zip: Part 2: Bank Information (Bank Representative fills this in this section) Routing Number: Account Number: Account type: Bank Name: Bank Address: City: Bank Phone Number: Bank Representative Signature (Required) (only select one) Checking: OR Savings: State: Zip: Date: Part 3: Vendor Signature Authorization (Vendor fills this in this section) Vendor Preparer's Name (Please Print): By signing below, I authorize to initiate/change my vendor payment direct deposit (EFT-Electronic Funds Transfer): Signature of Vendor (Required) Date: Save a Tree Choose EFT American LegalNet, Inc. www.FormsWorkFlow.com Revised 5/16/2014