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ACHAuthorization Form

This document is a vendor authorization agreement for direct deposit (ACH) payments. It contains sections for the vendor to provide their entity and financial institution information. The vendor authorizes the state agency (DCA) to initiate credit entries to the specified bank account, and also allows the financial institution to credit or debit the account as needed. The authorization remains in effect until revoked in writing by the vendor.

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gloria white
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Download as PDF, TXT or read online on Scribd
78 views

ACHAuthorization Form

This document is a vendor authorization agreement for direct deposit (ACH) payments. It contains sections for the vendor to provide their entity and financial institution information. The vendor authorizes the state agency (DCA) to initiate credit entries to the specified bank account, and also allows the financial institution to credit or debit the account as needed. The authorization remains in effect until revoked in writing by the vendor.

Uploaded by

gloria white
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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VENDOR AUTHORIZATION AGREEMENT FOR ACH PAYMENT

Directions
• Type or print the information requested in Sections 1 and 2. Then sign, date, and return the form with your Vendor
package.
• Any account changes must be reported to DCA within ten (10) days prior to actual change. A payee must keep DCA
informed of any address changes in order to receive important information about benefits and to remain qualified for
payments. Please refer to the application instructions, if applicable.

Section 1 - Entity to Receive Direct Deposit

Type of Transaction: Add Change Delete

Name of Company OR Individual County Telephone

Street Address City State Zip

Contact Person Email

9-digit Federal Tax ID

Section 2 - Financial Institution Authorized to Conduct Transaction

Financial Institution County Telephone

Street Address City State Zip

Type of Account
Checking Savings
9-digit Transit Routing/ABA Number

Account Number at Above Institution

Whereby we authorize DCA to initiate credit entries to our account in the financial institution our account identified above
and also debit entries, if necessary, for any credit entries that are determined to be in error. We additionally authorize the
financial institution to credit or debit the same to our account.
This authority is to remain in effect until revoked by us in writing to DCA.

Signature Title

Type or Print Name Date

For DCA use only Date Received Date Entered Initials


Rev: DCA 02/2021

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