turned Check Fee S S S Financial Institution Name: Authorized Signature- Print Name: For Metavante Use Only 8/t) 6 Telephone Date: 3 -/y-e) Bank 0 /Sn Agent sr /5- 3 Ext. Completed by Verification Date Date 233-09% MIDSLe (I2/01) Fax R9 requests to Collections, 608-240-7601; others to Account