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ACH and Wire Remittance
Section 1: Employer Information
Employer Code:
Employer Name:
Submitter's Name:
Submitter's Phone Number:
(
)
-
ext.
Section 2: Payment Method and Amount
Wire Transfer*
Date:
Total amount: $
ACH (Automated Clearing House)*
Date:
Total amount: $
* Complete a separate form for each wire transfer or ACH.