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212.277.8020 248 West 35
EFT FORM Instruction
Why do I need to fill out this form?
The electronic fund transfer form is required by our merchant service account in order to transfer funds
account. For the Fiscal Sponsorship program this relates specifically to the release of funds for projec
see https://www.fracturedatlas.org/site/fiscal/fund_release
Fractured Atlas requires BOTH a completed and signed EFT form
process an EFT request for a project.
Please note a voided check or account confirmation letter from your financial institution are used to verify account
information. Temporary/starter checks
Fractured Atlas EnrollmentSponsored Project associated with the EFT account.
related to the EFT bank account.
Banking Information:
Bank Account Holder Name: This should be the name of the person or business listed on the bank account and bank statements. This should also correspond with the name listed on the check. Bank Account Holder Address: Enter Bank Account Number: Enter the account number Bank Routing Number: Enter the routing number, *Bank Routing Numbers are typically found on the bottom left of a chec
Number is between these characters.
Name of Bank: List the name of the financial institution to which the funds will be deposited. Branch City, State, Zip: Enter the city, Type of Checking Account: Select if Account Holder Signature: This form must be signed by an Effective Date: This is the date the form is sFractured Atlas per the terms outlined on the form.
Please return only the completed and signed form along with a copy of a voided check by email, fax, or mail to:
Have other questions? Email us at **This instruction page is for your reference only. It should not be returned to Fractured Atlas with the form.
35th
St., Fl. 10 New York, NY 10001 www.fracturedatlas.org
EFT FORM Instructions Page: Fiscal Sponsorship
o I need to fill out this form?
The electronic fund transfer form is required by our merchant service account in order to transfer funds
ponsorship program this relates specifically to the release of funds for projec
https://www.fracturedatlas.org/site/fiscal/fund_release for details on how to request a fund release.
BOTH a completed and signed EFT form AND a void
an EFT request for a project. Please allow 1-2 business days for processing.
check or account confirmation letter from your financial institution are used to verify account
information. Temporary/starter checks are not accepted.
Fractured Atlas Enrollment: How do we know you at Fractured Atlas? Please enter the name of your
Sponsored Project associated with the EFT account. Do NOT list the Name of an Organization or Member who is not
related to the EFT bank account.
his should be the name of the person or business listed on the bank account and bank statements. This should also correspond with the name listed on the check.
Enter the address listed on your bank statement and check.
: Enter the account number to which funds will be deposited, including applicable leading zeros.
Enter the routing number, also referred to as the ABA number. It is ALWAYS 9 digits
typically found on the bottom left of a check. Find the special characters
Number is between these characters.
List the name of the financial institution to which the funds will be deposited.
ter the city, state, and zip code where your financial institution is located.
Select if your bank account is a personal account or a business account
: This form must be signed by an authorized account holder only.
: This is the date the form is signed. This also constitutes the date you authorize EFT trFractured Atlas per the terms outlined on the form.
completed and signed form along with a copy of a voided check by
[email protected] Fax: 212-277-8025
Mail to: Fractured Atlas 248 West 35
th Street, 10
th flr.
New York, NY 10001
Have other questions? Email us at [email protected] or call 888-692-7878**This instruction page is for your reference only. It should not be returned to Fractured Atlas with the form.
Fiscal Sponsorship
The electronic fund transfer form is required by our merchant service account in order to transfer funds to your bank
ponsorship program this relates specifically to the release of funds for project-related expenses,
for details on how to request a fund release.
a voided check to
for processing.
check or account confirmation letter from your financial institution are used to verify account
the name of your Fiscally
list the Name of an Organization or Member who is not
his should be the name of the person or business listed on the bank account and bank
including applicable leading zeros.
also referred to as the ABA number. It is ALWAYS 9 digits.
k. Find the special characters I: the Bank Routing
your financial institution is located.
account.
EFT transactions with
completed and signed form along with a copy of a voided check by
7878 **This instruction page is for your reference only. It should not be returned to Fractured Atlas with the form.
ELECTRONIC FUND TRANSFER SIGN UP FORMPlease see Instructions
Fractured Atlas Program Enrollment
o Artful.ly (enter Organization Name
o Fiscal Sponsorship (enter
______________________________________________________________________________________
Banking Information (all fields below are required
Bank Account Holder Name:___
Bank Account Holder Address:
Bank Account Holder Phone Number:_
Bank Account Number:___________
Bank Routing Number: ____________
Name of Bank:___________________________________________________________
Branch City, State, Zip:__________
Type of Checking Account: _______Personal _______Business
______________________________________________________________________________________
By completing and signing this form, I am confirming
Fractured Atlas to make electronic fund transfers into the named account, and, if necessary, make
withdrawals from the account to cover any negative account balances or transactions credited in error. I
understand a return fee may be applied if account information provided is incorrect.
ACCOUNT HOLDER SIGNATURE
Effective date:_________________ (this can be the current date)
This completed and signed form along
www.fracturedatlas.org
ELECTRONIC FUND TRANSFER SIGN UP FORMPlease see Instructions Page for information on completing this form.
Fractured Atlas Program Enrollment: Check off the program you’re enrolling in and enter details
Organization Name):_________________________________
enter Project Name):_____________________________________________
______________________________________________________________________________________
all fields below are required)
:______________________________________________________
Account Holder Address:_____________________________________________________________
Bank Account Holder Phone Number:_______________________________________________________
________________________________________________________________
________________________________________________________________
Name of Bank:___________________________________________________________
Branch City, State, Zip:____________________________________________________
Account: _______Personal _______Business
______________________________________________________________________________________
By completing and signing this form, I am confirming I am the bank account holder and authorizing
Fractured Atlas to make electronic fund transfers into the named account, and, if necessary, make
withdrawals from the account to cover any negative account balances or transactions credited in error. I
tand a return fee may be applied if account information provided is incorrect.
HOLDER SIGNATURE__________________________________________
Effective date:_________________ (this can be the current date)
completed and signed form along with a copy of a voided check must be returned to Fractured Atlas,
per the details listed in the Instructions Page.
ELECTRONIC FUND TRANSFER SIGN UP FORM for information on completing this form.
program you’re enrolling in and enter details
___________________________________________
__________________________
______________________________________________________________________________________
___________________________________
___________________________________________________________
______________________________________________________
________________________________________________________
_______________________________________________________
Name of Bank:___________________________________________________________
__________________________________________
________________________________________________________________________________________________
I am the bank account holder and authorizing
Fractured Atlas to make electronic fund transfers into the named account, and, if necessary, make
withdrawals from the account to cover any negative account balances or transactions credited in error. I
______________________
a copy of a voided check must be returned to Fractured Atlas,
