Wyoming > Workers Compensation
Change Of Name Address Or EFT WOLFS 109B - Wyoming
| Change Of Name Address Or EFT Form. This is a Wyoming form and can be used in Workers Compensation . |
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CLEAR FORM FIELDS STATE OF WYOMING WOLFS-109b Vendor Changes* The State of Wyoming must have a properly completed form before payment will be made. PLEASE RETURN THIS FORM TO STATE AGENCY CONTACT INFORMATION FOUND IN BOX TO THE RIGHT STATE AGENCY CONTACT INFORMATION Agency #, Agency Name, Contact Name, Title, Address; Phone # 053-DWS, Sue R., CBC, Ext 6283 Mail to: Workers' Compensation Division 1510 East Pershing Blvd Cheyenne, WY 82002 **If you have changed your EIN number or you have a new business name, please complete a new WOLFS109(a) vendor form. PART 1: Vendor Information VENDOR NUMBER from the VCUST2 Table: (State Agency fills this in) VENDOR NAME: (State Agency fills this in) Doing Business As (DBA), if applicable: (Vendor fills this in) Federal Employer Identification Number (FEIN): OR Social Security Number (SSN): Enter TIN HERE (FEIN or SSN)-- Do Not Use Dashes (Vendor fills this in) Note: Federal Tax ID or SSN must be the correct number for the tax reporting name. Part 2: Vendor Changes PROVIDE ONLY NEW INFORMATION Changes to an existing vendor only Check and complete only the applicable box(es): INDIVIDUAL NAME CHANGE**: Note: Individuals changing a name (as in the case of marriage or divorce) must notify both Social Security and IRS prior to submitting this form to the State agency. Business name changes must be submitted on a WOLFS-109a Vendor form. DBA NAME CHANGE: Address: ADDRESS CHANGE: City: State: Zip ESTABLISH A NEW DIRECT DEPOSIT AUTHORIZATION: I authorize electronic fund transfer (EFT) payment into my checking account by attaching either a copy of a voided check from my checking account or a certified letter from my financial institution, with the current information. CHANGE MY CURRENT BANKING INFORMATION: A copy of either a voided check from my checking account with the current information, or a certified letter from my financial institution with the current information, is attached. UPDATE SAVINGS ACCOUNT INFORMATION: A signed letter from my financial institution, has been attached, with the Account Type (i.e. checking or savings) identified, the ABA routing number, and account number provided. DISCONTINUE DIRECT DEPOSIT AUTHORIZATION: I understand by choosing this option, I will receive my payments via check in the mail, at the address on the file. Part 3: Certification I certify that the above information is accurate as of the date set out by me on this form. I am responsible for updating and maintaining my information whenever this information changes. SIGNATURE: PRINTED NAME: DATE: American LegalNet, Inc. www.FormsWorkFlow.com
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