A Better Way EFT Request Sheet
INSTRUCTIONS 1.) Fill out the form. 2.) Print. 3.) Fax or Mail the form to:      The EFT Center      313 NE Second Avenue      Delray Beach, FL 33444      Fax #: 866.590.3328
* Indicates a required field.
*COUNSELOR:
*CLIENT'S NAME:
*ADDRESS:
ADDRESS (cont.):
*CLIENT'S SSN:
*DATE OF 1st PAY:
*DATE OF 2nd PAY:
*DATE ELIGIBLE FOR EFT (3rd MONTH):
*MONTHLY PAYMENT AMOUNT: