STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION ELECTRONIC FUNDS TRANSFER (EFT) PAYMENT ENROLLMENT FORM DOT FA-2656 (REV 04/2025)Page 1 of 3 ADA NoticeAmericans with Disabilities Act (ADA) Notice: This document is available in alternative accessible formats. For more information, please contact the FormsManagement Unit at (279) 234-2284, TTY 711, in writing at Forms Management Unit, 1120 N Street, MS-89, Sacramento, CA 95814, or by email at [email protected].
PERSONAL INFORMATION NOTICE Pursuant to the Federal Privacy Act (5 U.S.C, Section 552 et seq.) and the Information Practices Act of 1977 (IPA) (Civil Code Sections 1798 et seq.) declares that the right to privacy is a personal and fundamental right protected by the California and United States Constitutions. Please be advised that this form requests personal information. The term “personal information” means any information that is maintained by an agency that identifies or describes an individual, including, but not limited to, the individual’s name, social security number, physical description, home address, home telephone number, education, financial matters, and medical or employment history. It includes statements made by, or attributed to, the individual. (Civil Code, § 1798.3, subdivision (a).)Information Collection and Access: California law requires the following information to be provided when collecting information from individuals. (See, for example, Civil Code, § 1798.17.)Agency Name and Division Within the Agency Requesting the Information:California Department of Transportation, Division of Acounting, Security & Workflow section of Office of Receivables, Systems and AdministrationTitle of Official Responsible for Information Maintenance:Debbie De Leon, Accounting administrator I @ 279-234-2910Maintenance of the Information Authorized By: Pursuant to the Federal Privacy Act (P.L. 93-579), and the Information Practices Act (IPA) of 1977 (Civil Code Sections 1798, et seq.), notice is hereby given for the request of personal information by this form.Consequences of Not Providing All or Any Part of the Requested Information:Disclosure of this information is voluntary. Failure to provide the requested information may delay processing of this form.Principal Purpose(s) for Which the Information Will Be Used:The principal purpose of the voluntary information is to facilitate the processing of this form. This form is used for Automated Clearing House (ACH) payments and contains payment-related information processed through the Department of Transportation's Automated Payment System.Known Disclosures:No disclosure of personal information will be made unless permissible under Article 6, Section 1798.24 of the IPA of 1977. Each individual has the right upon request and proper identification, to inspect all personal information in any record maintained on the individual by an identifying particular.Right of Access to Records:Individuals have the right to access information provided and may request a correction or deletion of records. Exceptions may include, but are notlimited to, investigations and public transparency laws. Personal Information will only be disclosed as permitted by the Information Practices Act,Civil Code, §§ 1798–1798.83, or as otherwise required by law. To request access to, or to request correction or deletion of, information provided inthis form you may contact the Official Responsible for Information Maintenance identified above.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION ELECTRONIC FUNDS TRANSFER (EFT) PAYMENT ENROLLMENT FORM DOT FA-2656 (REV 04/2025)Page 2 of 3 Americans with Disabilities Act (ADA) Notice: This document is available in alternative accessible formats. For more information, please contact the Forms ManagementUnit at (279) 234-2284, TTY 711, in writing at Forms Management Unit, 1120 N Street, MS-89, Sacramento, CA 95814, or by email at [email protected].
SECTION I DESIRED ACTIVITY - (TO BE COMPLETED BY PAYEE)Please check appropriate box(es):Change in EFT Contact Person or Phone NumberNew EFT AccountDelete EFT AccountChange in Bank Account or Mailing AddressSECTION IIEFT DEPOSITS - (TO BE COMPLETED BY PAYEE)The entire amount of our direct deposit payment IS ultimately deposited to a financial institution outside the U.S. (NOT ELIGIBLE FOR EFT)The entire amount of our direct deposit payment IS NOT ultimately deposited to a financial institution outside the U.S. (ELIGIBLE FOR EFT)Note: Please notify our office if this status changes so we can adjust your payment type from EFT to check.SECTION IIIPAYEE / COMPANY INFORMATION - (TO BE COMPLETED BY PAYEE)If applicable, CONTRACT NUMBER: Please use separate sheet to list, if needed.COMPANY NAME:FEIN # or SSN:ADDRESS:E-MAIL ADDRESS (IF APPLICABLE):CONTACT PERSON NAME:TELEPHONE #:SECTION IVFINANCIAL INSTITUTION INFORMATION - (TO BE COMPLETED BY FINANCIAL INSTITUTION)FINANCIAL INSTITUTION NAME:ADDRESS:ACH COORDINATOR NAME:TELEPHONE #:NINE DIGIT ROUTING TRANSIT NUMBERDEPOSITOR ACCOUNT NUMBER (NOT TO EXCEED 17 DIGITS)TYPE OF ACCOUNT:CheckingSavingsSIGNATURE OF AUTHORIZED BANKING OFFICIAL:PRINT NAME:TITLE OF OFFICIAL:TELEPHONE #:SIGNATURE OF AUTHORIZED CONTACT PERSON:DATE:By providing my electronic signature for this form, I agree to conduct business transactions by electronic means and that my electronic signature is the legal binding equivalentto my handwritten signature. I hereby agree that my electronic signature represents my execution or authentication of this form, and my intent to be bound by it.
SECTION V - Return this form to:AGENCY INFORMATION - (TO BE COMPLETED BY THE DEPARTMENT OF TRANSPORTATION)STATE AGENCY: Department of TransportationVENDOR #:ADDRESS: Division of Accounting - MS 33 Attn: Suet Wong/Payee Data Records P.O. Box 168043 Sacramento, CA 95816 PHYSICAL 1820 Alhambra Blvd. ADDRESS: Sacramento, CA 95816For questions only, e-mail: Note: Please mail original documents: (1) EFT Form and (2) voided check or a bank reference letterCONTACT PERSON NAME: Suet WongTELEPHONE #: (279) 234-2823Payee Data [email protected] STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION ELECTRONIC FUNDS TRANSFER (EFT) PAYMENT ENROLLMENT FORM DOT FA-2656 (REV 04/2025)Page 3 of 3 Americans with Disabilities Act (ADA) Notice: This document is available in alternative accessible formats. For more information, please contact the Forms ManagementUnit at (279) 234-2284, TTY 711, in writing at Forms Management Unit, 1120 N Street, MS-89, Sacramento, CA 95814, or by email at [email protected].
This form is used for Automated Clearing House (ACH) payments and contains payment-related information processed through the Department of Transportation's Automated Payment System. Recipients of these payments should bring this information to the attention of their financial institution when presenting this form for completion. PERSONAL INFORMATION NOTICE Pursuant to the Federal Privacy Act (P.L. 93-579), and the Information Practices Act (IPA) of 1977(Civil Code Sections 1798, et seq.), notice is hereby given for the request of personal information by this form. The requested personal information is voluntary. The principal purpose of the voluntary information is to facilitate the processing of this form. The failure to provide all or any part of the requested information may delay processing of this form. No disclosure of personal information will be made unless permissible under Article 6, Section 1798.24 of the IPA of 1977. Each individual has the right upon request and proper identification, to inspect all personal information in any record maintained on the individual by an identifying particular. Direct any inquiries on information maintenance to your IPA Officer.ACCOUNT VALIDATION For the purpose of EFT payments, vendors are requested to ensure the account specified on this enrollment form remains active until receipt of the last anticipated EFT payment into the referenced account. This assurance will assist in the guarantee of prompt payment. Please note: If any vendor's account is deemed "invalid" at any time during the EFT process, that specific vendor will be contacted and a new updated and completed enrollment form will be required. Vendors complete Sections I, II, and III.Financial Institutions complete Section IV.Caltrans completes Section V.Instructions for Completing EFT Enrollment Form Section I Desired Activity - Payee checks the box indicating the desired action (e.g. add, modify, delete). Section II EFT Deposits - Check the first box if the entire amount of the direct deposit IS ultimately deposited outside the U.S. Check the second box if the entire direct deposit IS NOT ultimately deposited outside the U.S. (The National Automated Clearing House Association (NACHA) requires international ACH Transactions (IAT) be identified. Payments ultimately deposited to a financial institution outside the U.S. are not eligible for Electronic Funds Transfer (EFT).Section III Payee / Company Information - Payee prints or types the name of the payee/company and address that will receive ACH vendor/ miscellaneous payments, Federal Employer ID (FEIN) or Social Security Number (SSN), designated contact person and assigned telephone number.Section IV Financial Institution Information - Financial institution prints or types the name and address of the payee/company's financial institution who will receive the ACH payment, ACH coordinator name and telephone number, nine-digit routing transit number, depositor (payee/company) account title, and account number. The financial institution checks the appropriate box indicating the type of account to be used (e.g. checking or savings), enters the title and telephone number of the appropriate financial institution official, and signs the form as the authorized banking official. Footnote - Financial Institution Information - An original voided check or savings deposit slip must be attached to the completed authorization agreement (enrollment form). Your voided document will aid in verifying bank account and routing transit numbers. An example of a voided check, shown below, indicates where to locate the routing transit number for your bank and your bank account number. Remember to mark the word "VOID" across the front of your check or savings deposit slip that you return with this authorization agreement. ABC BUSINESS 1044 1234 Boomtown Anytown,CA ___________20___ Pay to the Order of ____________________________________$ ___________________________________________________________DOLLARS U.S.A. Memo _______________Not Negotiable_________(1) 1:133404567 (2) 1:1234561304 111 (3) 1044VOIDVOIDVOID(1)Routing Transit Number(Required 9 digits) (2)Bank Account Number (Not to exceed 17 digits) (3)Check NumberIf unable to obtain an original voided check, the bank must provide a letter referencing the vendor name and account information. The letter must include the signature and title of an authorized bank representative. Section V Agency Information - This section is filled out by the State Agency with the address of where this form is to be returned. The designated contact person's name and telephone number are also listed, along with an e-mail address. The vendor # may be filled out by the State Agency when the form is sent out or when the form is returned to the Agency.
Instructions