Online Direct Deposit Form

I hereby authorize Confederated Tribes of Siletz Indians to initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit entries in error to my account listed above. The authorization will remain in effect until I have filed a new authorization, or until this authorization is revoked by me in writing. I CERTIFY THAT I AM AUTHORIZED TO PROVIDE THE INFORMATION AND SUBMIT THIS FORM AS THE ACCOUNT HOLDER.

I hereby CANCEL direct deposits with the Tribe from this date forward until I complete another form. I CERTIFY THAT I AM AUTHORIZED TO PROVIDE THE INFORMATION AND SUBMIT THIS FORM AS THE ACCOUNT HOLDER.