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Get 459-475 Automatic Clearing House Agreement Form.indd

Ated Clearing House (ACH) Agreement Section A: Employer information (Type or print clearly in black ink. Illegible forms may be returned to applicant. This could delay your request.) Employer name Employer number Mailing address (street or PO box) City State Phone number Zip E-mail Section B: ACH Debit q ACH debit election If you choose this option, go to the PERS employer website. Complete the Authorization Agreement for Employer ACH Debits form. Mail signed originals of both the Empl.

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