STATE OF WISCONSIN, DEPARTMENT OF VETERANS AFFAIRS

201 West Washington Avenue, P.O. Box 7843, Madison, WI 53707-7843

(608) 266-1311 1-800-WIS-VETS (947-8387)

AUTHORIZATION AGREEMENT FOR RESTRICTED (ACH OR DTC) DEBITS
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04(1)(m)].

US BANK MILWAUKEE	ROUTING NUMBER: 0750-0002-2

777 E. Wisconsin Ave.

Milwaukee, WI 53202

SERVICER
SERVICER
NAME	NUMBER	___ ___ ___
I (we) hereby authorize US BANK MILWAUKEE, hereinafter called ORIGINATOR, to initiate debit entries to the demand deposit checking account (WDVA CUSTODIAL ACCOUNT) indicated below and the depository financial institution named below, hereinafter called DEPOSITORY, to debit the same to such account.
DEPOSITORY
NAME	ADDRESS
CITY	STATE	ZIP
ROUTING
ACCOUNT
NUMBER	NUMBER
This authority is to remain in full force and effect until ORIGINATOR and DEPOSITORY receive written notification of termination in such time and in such manner as to afford ORIGINATOR and DEPOSITORY a reasonable opportunity to act on it.
SERVICER
PHONE
NAME
NUMBER
SERVICER
SIGNATURE
DATE
TO BE COMPLETED BY THE DEPOSITORY
ROUTING NUMBER
ACCOUNT NUMBER *
* Please include only required dashes in account number
DEPOSITORY
PHONE
NAME	NUMBER
DEPOSITORY
SIGNATURE
DATE

WDVA 1141

AUTHORIZATION AGREEMENT FOR RESTRICTED (ACH OR DTC) DEBITS

Purpose:	To authorize US Bank Milwaukee to initiate debit entries to a WDVA Custodial Account, and to authorize Servicer’s DEPOSITORY to debit such entries.

Prepared By:	Servicer

Distribution:	Servicer forwards Original to DEPOSITORY.

DEPOSITORY inserts Transit Routing Number and Account Number on AUTHORIZATION AGREEMENT FOR RESTRICTED (ACH OR DTC) DEBITS, signs Authorization Agreement, and sends Original to:	Wisconsin Department of Veterans Affairs

ATTN: Loan Accounting

P.O. Box 7843

Madison, WI 53707-7843

Instructions

It is no longer necessary to remit Bond Type GO, Bond Type RA, and Bond Type RB activity separately. The combined Bond Type GO, RA, and RB activity is remitted using the Bond Type GO company number, location number, and password.

Servicer Name:	Servicer’s Corporate Name.

Servicer Number:	Three-digit number assigned by WDVA.

DEPOSITORY Name and Address.

DEPOSITORY Transit Routing Number.

WDVA Custodial Account Number at DEPOSITORY.

Servicer Name, Phone Number:	Name and Phone Number of person completing form.

Servicer Signature, Date:	Signature of person completing form; and Date form was prepared.

WDVA 1141 (04/07) Page 2 of 2	You can access the most recent version of this form

W:\Templates\WDVA_1141_Authorization_Agreement_for_Restricted_ACH_or_DTC_Debits.dot	from the WDVA website at www.WisVets.com/Forms.

WDVA 1141 (04/07) Page 1 of 2	You can access the most recent version of this form

Wis. Stats. Chapter 45

WDVA 1141 - AUTHORIZATION AGREEMENT FOR RESTRICTED (ACH OR DTC) DEBITS

memerka

2012-01-23

Karen Emery

Dept of Veterans Affairs