Get Payment Method Authorization Form (f120-211-000) - L&i

The Payment Method Authorization Form (F120-211-000) is essential for users looking to request a new payment method or change their existing one with L&I. This guide provides clear, step-by-step instructions to ensure you can complete the form accurately and efficiently.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it for editing.
2. Fill out your claimant information. Include your Claim/Folio/L&I Account Number and your Claimant Name in the appropriate fields.
3. If you wish to receive a paper check for your payments, just sign at the bottom of the form. No other sections will need to be completed.
4. Complete the person receiving payment information section. Provide your last name, first name, middle initial, Social Security Number, mailing address, city, state, date of birth, phone number, and optional email address.
5. If you wish to receive direct deposit, indicate this by selecting the option, then provide your bank information: Bank Name, Account Type (checking or savings), Routing Number, and Bank Account Number.
6. If you would like to receive an L&I debit card for your payments, select this option and provide the Routing Number and an Account Number for your bank.
7. Review the authorization statements at the bottom of the form. Make sure to understand and acknowledge the terms outlined.
8. Sign and date the form to confirm your requests.
9. Once you have filled out the form completely, you can save your changes, download, print, or share the form as necessary.
10. Return the completed form to the Department of Labor and Industries via mail or fax using the provided details.

Complete your Payment Method Authorization Form online today for a smooth transition to your preferred payment method.