ACH VENDOR PAYMENT AUTHORIZATION FORM
ACH VENDOR PAYMENT AUTHORIZATION FORM
This form is used for Automated Clearing House (ACH) payments. The information being collected on this form will be used by the State Comptroller’s office to transmit payment data, by electronic means, to a vendor’s financial institution. Failure to provide the requested information may delay or prevent the receipt of payment through ACH Payment System. Recipients of the payments 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 change occurring at the financial institution that may delay or prevent the receipt of scheduled payments.
This Section to be completed by Vendor (College)
This Section to be completed by Financial Institution (Bank)
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VENDOR INFORMATION
NAME:____________________________________________________________
ADDRESS:_________________________________________________________
CONTACT NAME:__________________________________________________
FEDERAL I.D.#:____________________________________________________
__________________________________________________________________
AUTHORIZED SIGNATURE
AGENCY INFORMATION
NAME: ALABAMA COMMUNITY COLLEGE SYSTEM
ADDRESS: P.O. BOX 302130, MONTGOMERY, AL 36130-2130
CONTACT NAME: ROBIN HEAD PHONE: 334/293-4623
FINANCIAL INSTITUTION INFORMATION
NAME:___________________________________________________________
ADDRESS:________________________________________________________
ACH COORDINATOR NAME:_______________________________________
(9) DIGIT ROUTING NUMBER:______________________________________
DEPOSITOR ACCOUNT TITLE:______________________________________
DEPOSITOR ACCOUNT NUMBER:___________________________________
TYPE OF ACCOUNT: π CHECKING π SAVINGS
___________________________________________ (______)_______________
SIGNATURE & TITLE OF REPRESENTATIVE PHONE NUMBER
Please complete three (3) copies of this form with ORIGINAL signatures:
1) Retain one copy for college’s records
2) Financial Institution should retain one copy
3) Return one copy to Alabama Community College System,
Attention: Robin Head, P.O. Box 302130, Montgomery, AL 36130
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