DIRECT DEPOSIT SIGN-UP FORM

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					                                                                                                                                        Form 335
                                                                                                                                       V20100517




                                                     ACCOUNTS PAYABLE
          DIRECT DEPOSIT (ACH) ENROLLMENT FORM AND AGREEMENT
                                                     Please Print or Type All Information


       Company/Payee Name:

                         Address:



                 City/State/Zip:
                                                                  City                                     State                 Zip

     Company/Payee Contact
                   Person:                                                                          Phone:
   Company/Payee Contact E-
                      mail:




    Financial Institution Name:

   Financial Institution Phone:


              Routing Number:                                                                                              (9 digits)

        Depositor Account No.:                                                                Type:         Checking          Savings



I hereby authorize The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. (“HJF”) to
automatically deposit payments to the account listed above under the terms and conditions of this Direct Deposit
(ACH) Enrollment Form and Agreement. I certify that I am authorized to enter into this agreement on behalf of
the account holder. I verify that the information provided on this form is correct and that HJF may rely on it.


 Authorized Signature:                                                                           Date:

                    Title:


For HJF Internal Use Only
                                                                                                    Initials              Date
            Vendor ID
    Banks/Counterparts
       Vendor Account
   Vendor File Updated
     Manager Approval


                             ** Instructions and Terms and Conditions on reverse **
         1401 Rockville Pike · Suite 600 · Rockville, Maryland 20852 · Telephone: (301) 424-0800 · Fax: (240) 314-7304 · www.hjf.org
                                                                                                                   Form 335
                                                                                                                  V20100517


                       *** INSTRUCTIONS TO PAYEE/VENDOR ***

  1. The Direct Deposit (ACH) Enrollment Form and Agreement allows HJF’s Accounts
     Payable Department to automatically deposit payments directly into a financial account
     of a vendor.

  2. Complete the form.

  3. Sign and date where indicated and forward the completed form to the HJF Accounting
     Office for processing. Send the completed form to:

                 The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc.
                 Attn: Accounts Payable Department
                 1401 Rockville Pike, Suite 600
                 Rockville, MD 20852

  4. All accounts will be prenoted (tested) to ensure the information provided is valid.
     During this prenote, payees/vendors will continue to receive negotiable checks in the
     mail.

  5. Incorrectly completed forms may cause significant delays in establishing direct deposit
     payments.

                               *** TERMS AND CONDITIONS ***

  1. Payee/Vendor agrees to accept payment by HJF through electronic funds transfer (EFT)
     and that HJF can rely on the information provided on the front of this form.

  2. This agreement applies to and amends all agreements with HJF by incorporating these
     terms and conditions for electronic payment. However, these terms and conditions
     neither enlarge nor diminish the respective rights and obligations contained in any other
     agreement with you. The payment terms are not affected. HJF will consider payment
     received by you when your financial institution has received or has control of the
     payment.

  3. Payments to you will be deposited into the account designated on the front of this Direct
     Deposit (ACH) Enrollment Form and Agreement until HJF is notified in writing that you
     wish to cancel this authorization or designate a different financial institution or account.
     A minimum of ten banking days will be needed to execute your instructions.

  4. HJF has the right to adjust future payments if payments previously made are found to
     be duplicates, in excess of requirements, fraudulent, in error, or require any other
     adjustment under the terms of an agreement with you. This may be accomplished by
     using an ACH debit.

  5. HJF will not be responsible for any loss arising solely from error, mistake, or fraud
     regarding information on your Direct Deposit (ACH) Enrollment Form and Agreement.




1401 Rockville Pike · Suite 600 · Rockville, Maryland 20852 · Telephone: (301) 424-0800 · Fax: (240) 314-7304 · www.hjf.org