Vendor ACH Enrollment Form

Vendor ACH Enrollment Form
This form is used for Automated Clearing House (ACH) payments to provide payment-related information to your financial institution. Information on this form is subject to additional verification to ensure accuracy and prevent fraud. Please allow up to two(2) weeks to process the ACH enrollment. if you have any Questions, please contact Accounts Payable at 410-386-2001 or email at acctspayable@carrollcountymd.gov.
Is this a:

New RequestChange Request
VENDOR INFORMATION (Remit Address)
VENDOR NAME*
TAXPAYER ID (Required)*
Address*

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
ACCOUNTING CONTACT NAME
Telephone Number*
FAX NUMBER
EMAIL ADDRESS (PRINT CLEARLY) – *Required to receive remittance.*
example@example.com
FINANCIAL INSTITUTION INFORMATION
BANK NAME*
Address

ADDRESS

Street Address Line 2

CITYSTATE

ZIP
ACCOUNT NAME
ACH ROUTING NUMBER (9 Digits)*
ACCOUNT NUMBER*
Account Type

CHECKINGSAVINGS
IF CHANGE REQUEST, LAST 4 DIGITS OF PRIOR BANK ACCOUNT NUMBER
Certification:
I certify I am responsible for notifying any changes to the information provided above to Carroll County Government. I agree to immediately return any erroneous payments that may occur as a result of payment via ACH. I certify the information provided on this form is true and correct, and that I, as an authorized representative for the above named company, authorize Carroll County Government to electronically deposit payments into the designated bank account. This authority remains in full force until written notice of change or cancellation is received by Carroll County Government. Carroll County Government reserves the right to cancel or suspend this authorization at any time.
Authorization:
Authorized Official Name*
Signature *

Clear
Title
Date

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Vendor ACH Enrollment Form

VENDOR INFORMATION (Remit Address)

FINANCIAL INSTITUTION INFORMATION

Certification:

Authorization: