College of Nursing and Allied Health
Authorization for ACH/EFT and W-9
Individual
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SNIP Program
CNAH Mentorship Program
Jag Mobile (Nursing/Mental Health)
Other
W-9 Form
Download W-9. Complete lines 1, 3a, 5, 6, Part I Social Security Number and sign/date Part II Certification. Incomplete/Unsigned forms will be rejected.
Upload Completed W-9 Form (PDF only)
Browse Files
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Payee Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Full SS Number
*
Example: ###-##-####
EIN (Businesses Only)
Example: ##-####### (Businesses Only)
Southern University U Number
Example: U01234567. (Southern University Faculty, Staff or Student Only)
SUS Email Address
Personal Email Address
example@example.com
Bank Information
Bank Name
*
Branch Address
*
Street Address
Street Address Line 2
City
State / Province
Zip Code
Bank Routing Number (ABA#)
*
Checking Account Number
*
Authorized Signature: By executing this document, I authorize the Southern University System Foundation to deposit all payments into the account listed below. Attached to this form are a completed authorization for disbursement form and supporting documentation; e.g., original invoices, original receipts, contracts, etc
*
Today's Date
*
-
Month
-
Day
Year
Date
Submit
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