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Electronic Deposit Authorization

If you would like to receive your Optuma payments via electronic deposit, please read, complete and sign this authorization form. Note that in some jurisdictions this is now the only method by which you can be paid by Optuma.

Company Name

Contact Name

Address Details

Email Address

Address Line 1

Address Line 2

City

State/Province

Zip/Postal Code

Country

Account Details

Routing Number

Account Number

Account Type

By signing this form, I authorize Optuma Pty Ltd to deposit funds directly into the account indicated below. I warrant that the details are correct, and I am responsible for any loss of funds associated with errors on this form.

Signed Date

April 27, 2024

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Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

June 6, 2019 11:17 am AEST

Electronic Deposit Authorization Uploaded by Mathew Verdouw - [email protected] IP 192.168.25.25