Change in Landlord Information

Last Name(Required)

First Name(Required)

Full Business Name

Contact Name

Phone Number(Required)

Fax Number

Federal ID Number

Email(Required)

Correspondence Address

Address(Required)

City(Required)

State(Required)

Zip(Required)

Check and 1099 Address (If Different)

Address

City

State

Zip

I would like Bangor Housing Authority to deposit the housing assistance payment check directly to your bank account.

Yes

No

Bank Information

Bank Name

Contact Name

Address

City

State

Zip

Phone

Route Number

Fax/Modem

Account Number

Account Type

Checking

Savings

Authorization for Direct Deposit

I authorize Bangor Housing Authority to automatically deposit/charge any funds owed to me to my account at the Depository Financial Institution named above and to make adjustment entries, if necessary. I understand that this agreement may be terminated by me or by the Bangor Housing Authority at any time by written notification. Any such notification requires a reasonable time to act upon it.

I have read and understood both parts of this form:

Signature(Required)

Date(Required)

MM slash DD slash YYYY

Printed Name(Required)

Facebook

BangorHousing

Phone: 207-942-6365

Fax: 207-942-6043

161 Davis Road
Bangor, ME 04401
Apply for Housing

Website by Pulse Marketing