Vendor/Grantee ACH/Direct Deposit Authorization Form

Vendor/Grantee ACH/Direct Deposit Authorization Form
1. Please Check One

NEW Direct DepositCHANGE Direct DepositCANCEL Direct Deposit
Name
Address
Contact Person’s Name (if other than payee)
Telephone Number
Email Address
example@example.com
Additional Email Recipient (i.e. Development Officer, Finance Department, Bursar's Office)
example@example.com
3. Financial Institution Information
Bank Name
Bank Address
Name on Bank Account
Bank Account Number
Nine-Digit Bank Routing/Transit Number (ABA)
Type of Account

CheckingSavings
4.Approvals/Authorizations - I certify that the information provided on this form is correct, and I hereby authorize Berks County Community Foundation to electronically deposit payments to the bank account designated above. It is my responsibility to notify Sally Cox, Finance and Operations Administrator (sallyc@bccf.org or (610) 685-2223) immediately if I believe there is a discrepancy between the amount deposited to my bank account and the amount of the invoice(s) paid. I understand that I must notify Sally Cox in writing immediately of any changes in status or banking information. I understand that this authorization will remain in full force and effect until written notification is received requesting a change or cancellation and has had reasonable opportunity to act on it, which should take no longer than seven (7) to ten (10) business days.
Print Name
Signature

Clear
Date

MonthDayYear
Date
Please attach a copy of a voided check

Cancelof
Should be Empty: