ACH VENDOR/MISC PAYMENT ACH AUTHORAZATION FORM

ACH VENDOR/MISC PAYMENT ACH AUTHORAZATION FORM
Please fill out the information below. A member of the Town will contact you if any further information is needed. This form is used for Automated Clearing House (ACH) payments. The information collected on this form will be used by the Town of Shipshewana to transmit payment data, by electronic means, to a vendor's or individual's financial institution. Failure to provide the requested information may delay or prevent receipt of payment through ACH. Recipients of the payment should bring this information to the attention of their financial institution when presenting this form for completion. Recipients should also request to be notified immediately regarding any changes occurring at the financial institution that may delay or prevent the receipt of scheduled payments.
PAYEE/VENDOR INFORMATION
PAYEE/VENDOR NAME
TAXPAYER ID NUMBER
ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHONE
Format: (000) 000-0000.
FAX NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
EMAIL ADDRESS
example@example.com
BILLING CONTACT PERSON(S)
BILLING PHONE NUMBER
Format: (000) 000-0000.
BILLING FAX NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
BILLING EMAIL ADDRESS
example@example.com
FINANCIAL INSTITUTION INFORMATION
BANK NAME
BANK ADDRESS

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ROUTING NUMBER (9 DIGITS)
BANK ACCOUNT NUMBER
ACCOUNT TYPE
TAKE PHOTO/ATTACH IMAGE OF VOIDED CHECK
CERTIFICATION & AUTHORIZATION
- I certify I am responsible for notifying any changes to the information provided above to the Town of Shipshewana.
- I certify that I agree to immediately return any erroneous transactions 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 or individual, herby authorize the Town of Shipshewana to electronically deposit payments to the designated bank account and, if necessary, initiate adjustments for any transactions credited or debited in error. This authorization remains in full force until written notice of change or cancellation is received by the Clerk-Treasurer of the Town of Shipshewana. The Town of Shipshewana reserves the right to cancel or suspend this authorization at any time.
AUTHORIZED OFFICIAL NAME (PLEASE PRINT)
TITLE (IF APPLICABLE)
AUTHORIZED OFFICIAL SIGNATURE
DATE

MonthDayYear
Date
Should be Empty:

ACH VENDOR/MISC PAYMENT ACH AUTHORAZATION FORM

PAYEE/VENDOR INFORMATION

FINANCIAL INSTITUTION INFORMATION

CERTIFICATION & AUTHORIZATION