MDL Preferred Payment Method

Name*

First and Last name for check or direct deposit
Email*
Is this a revised payment form?*
- No, this is not a revision
- Yes, this is a revised form
If you've filled out this online form in the past and this is a revision (error before, change in account) please mark this as a revised form.
Preferred Payment Type*
Street Address*
City, State*
Zip*
Bank Name*
Bank Account Number*
Checking or Savings?*
9 Digit Routing Number*

Note: This number sometimes starts with a zero. Please include the zero.

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