CMHPSM New Vendor Form

CMHPSM New Vendor Form
Request Type:*

New Vendor Information SubmissionExisting Vendor Information Update
Update (Select Each Item to Update)*

General Vendor InformationW-9Banking Information
New Vendor Name:*
New DBA or Business Name if Different:
Vendor Type:*

Individual/sole proprietor or single-member LLCC CorporationS CorporationPartnershipLimited Liability CompanyOther
Other:
Federal ID
or
Social Security #
New Vendor Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
New Main Phone:*

Area CodePhone Number
New Main Fax:*

Area CodePhone Number
All CMHPSM vendors must submit a signed W-9 form and upload it below.
Link to fillable PDF copy of W-9 form: Federal W-9 Form
W-9 Upload

Upload a File

Cancelof
Contact Name:*

First NameLast Name
Contact Phone:*

Area CodePhone Number
Contact E-mail:*
All CMHPSM vendors will be paid through an electronic direct payment via ACH, instead of paper checks, unless the CMHPSM approves a paper check for an emergency or as an exception.
Existing Financial Institution Name:*
Existing Routing #:*
Existing Account #:*
Existing Account Type:*

CheckingSavings
Existing Remit E-mail:*
example@example.com
New Financial Institution Name:*
New Routing #:*
New Account #:*
New Type:*

CheckingSavings
New Remit E-mail:*
I understand this authorization remains in effect until cancelled by the Vendor or the CMHPSM. I authorize the CMHPSM to recover money electronically deposited in error by either debiting my account or by adjusting future payments. I understand I will be notified if an error does occur. Michigan law governs electronic funds transactions authorized by this agreement in all respects except as otherwise superseded by federal law.

Vendor agrees to these stipulations by checking the agree box or signing or typing in the signature box:
Authorizer:*

First NameLast Name
Date:*

MonthDayYear
Agree:*

Agree to Conditions
Should be Empty: