Provider Accounts Change Form For Crime Victims Compensation {F800-089-000}

State of Washington Department of Labor and Industries Crime Victims Compensation Program PO Box 44520, Olympia, Washington 98504-4520 Phone: (360) 902-5377 Fax: (360) 902-5333 PROVIDER CHANGE FORM FOR CRIME VICTIMS COMPENSATION Please read all instructions before completing the Provider Change Form. 1.) TAX ID Address/Name Change: If you have a tax ID address/name change, please complete Form W-9, and mail or fax to Provider Accounts. 2.) Business Address: (Physical location of the business.) Complete this section with your OLD and NEW business address. This is the physical location of your business. It cannot be a PO BOX. 3.) Billing Address: (If different than your physical location) Complete this section with your OLD and NEW billing address. This is where payments Should be mailed. If this is the same as your physical address write "same" in the box. Name Change: Submit copy of new license showing name change. If your name change effects tax information refer to section 1 . 4.) 5.) Provider Account Termination: Please complete the reason for Provider Account termination, name of provider to be terminated, provider number, Tax ID number and effective date of termination. Tax ID Number Change: If you have a tax ID number change, please complete a new provider application and Form W-9 and return it to the appropriate address on the form. Please include a list of all providers with their provider account numbers who should be changed to the new tax ID number. The Form W-9 must show the effective date of the change. Forms referenced above can be located on the Internet at: http://www.lni.wa.gov/ClaimsIns/CrimeVictims/FormPub F800-089-000 Provider Change Form for CVC 03-2012 American LegalNet, Inc. www.FormsWorkFlow.com Crime Victims Compensation Program Department of Labor and Industries PO Box 44520 · Olympia, Washington 98504-4520 Phone: (360) 902-5377 Fax: (360) 902-5333 PROVIDER CHANGE FORM FOR CRIME VICTIMS COMPENSATION Please carefully read all Instructions before completing form. * Required Fields Address Change: *Provider Number: Send this form to the address at the top of page. Contact us at: 1-800-762-3716 · Fax: (360) 902-5333 Unless otherwise notified, your claims related correspondence will go to your business (physical) address. Please check this box if you would like all your mail to go to the billing address. Physical Address: (Where you would like to receive general correspondence; cannot be a PO Box) Old Physical Address: Address City Phone State ZIP New Physical Address: Address City Phone State ZIP Billing Address: (Where you would like checks mailed) Old Billing Address: Address City Phone State ZIP New Billing Address: Address City Phone State ZIP Name: (Name as it appears on your license) Provider Number: Old Name: Provider Account Termination: New Name: I wish to terminate the provider account number below for the following reason: Provider Number: Provider Name: Effective Date: Tax Information Change: (Please check appropriate box and attach current W-9 form.) Tax Identification Number: Name Change: Address Change: Number Change: (ATTENTION) Provider Number and signature required below for processing. *Date: *Provider Number: *Signature: F800-089-000 Provider Change Form for Crime Victims Compensation 03-2012 American LegalNet, Inc. www.FormsWorkFlow.com PLEASE DO NOT STAPLE Statewide Payee Registration & W-9 Form Washington State STEP 1: Is this a NEW registration or CHANGE to an existing registration (check one)? NEW REGISTRATION (also includes changing the LEGAL NAME, SSN, EIN or reporting type) CHANGE to EXISTING REGISTRATION ­ complete the ENTIRE form and check below what is updated: Business Name/DBA Business Address Contact Information Bank, Routing or Account Numbers Payment Options If you know your Statewide Vendor Number, enter it here: SWV: - STEP 2: Enter information about the payee and contact person Legal Name of Payee as it appears on federal tax forms EIN or SSN for the Legal Name at left Business Name, if different from Legal Name above ­ eg. Doing Business As (DBA) Name Contact Person Mailing Address for us to send notifications or payments ­ PO Box or Street Address Title of Contact person ( Mailing Address ­ Suite or Office Number ) ) N Ext. Telephone Number for Contact Person City State Zip + 4 ( / MIPSC / Fax Number for Contact Person 2350 Email for us to use ONLY to send you notifications about your account / / L&I Provider # L&I # / System / Client Type (Above Line for L&I Office Staff Only) STEP 3: Select Payment Option: Direct Deposit to bank (recommended) or Check in US mail Note: Register now for Direct Deposit available January 2013. STEP 4: For Direct Deposit, complete all fields below and sign ( Financial Institution Name ­ must be a US institution ) - Financial Institution Phone Number EXAMPLE Routing Number ­ see example at right Account Number ­ see example at right You may also attach a voided check if you are unsure which number to enter above Account Type: Checking or Savings (Checking will be used if neither box is marked.) routing Number (nine digits) account number can vary in length Authorization for Direct Deposit: I hereby authorize and request the Office of Financial Management (OFM) and the Office of the State Treasurer (OST) to initiate credit entries for payee payments to the account indicated above, and the financial institution named above is authorized to credit such account. I agree to abide by the National Automated Clearing House Association (NACHA) rules with regard to these entries. Pursuant to the NACHA rules, OFM and OST may initiate a reversing entry to recall a duplicate or erroneous entry that they previously initiated. I understand that, if a reversal action is required, OFM will notify this office of the error and the reason for the reversal. This authority will continue until such time OFM and OST have had a reasonable opportunity to act upon written request to terminate or change the direct deposit service initiated herein. Authorization Name on Account Title SIGNATURE of Authorization Name on Account Date Page 1 of 2 Substitute Statewide Payee/W-9 form 3/2012 American LegalNet, Inc. www.FormsWorkFlow.com STEP 5: Complete and sign the Request for Taxpayer Identification Number (W-9) Substitute Form W-9 Request for Taxpayer Identification Number and Certification 1. Legal Name (as shown on your income tax return) 2.Business Name, if different from Legal Name above ­ eg. Doing Business As