ACH VENDOR PAYMENT AUTHORIZATION FORM
ACH VENDOR PAYMENT AUTHORIZATION FORMThis form is used for Automated Clearing House (ACH) payments. The information being collected on this form will be used by Share Our Strength, Inc. to transmit payment data, by electronic means, to your 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 Vendor72390059690VENDOR INFORMATIONNAME :____________________________________________________________ADDRESS :_________________________________________________________CONTACT NAME :__________________________________________________CONTACT EMAIL & PHONE:________________________________________FEDERAL I.D.#:_______________________________________________________________________________________________________AUTHORIZED SIGNATURE00VENDOR INFORMATIONNAME :____________________________________________________________ADDRESS :_________________________________________________________CONTACT NAME :__________________________________________________CONTACT EMAIL & PHONE:________________________________________FEDERAL I.D.#:_______________________________________________________________________________________________________AUTHORIZED SIGNATURE723900111760ORGANIZATION INFORMATIONNAME: Share Our Strength, Inc.ADDRESS:1030 15th Street, NW, Suite 1100 West Washington, DC 20005CONTACT NAME:Kim Rivens, Accounts Payable Associate(202) 478-6501; krivens@ 00ORGANIZATION INFORMATIONNAME: Share Our Strength, Inc.ADDRESS:1030 15th Street, NW, Suite 1100 West Washington, DC 20005CONTACT NAME:Kim Rivens, Accounts Payable Associate(202) 478-6501; krivens@ This Section to be completed by Financial Institution (Bank)723331-199FINANCIAL INSTITUTION INFORMATIONBANK NAME:__________________________________________________________________BANK ADDRESS:_______________________________________________________________(9) DIGIT ROUTING NUMBER:___________________________________________________DEPOSITOR ACCOUNT NAME:__________________________________________________DEPOSITOR ACCOUNT NUMBER:_______________________________________________TYPE OF ACCOUNT: □ CHECKING □ SAVINGS__________________________________________________ (______)_______________SIGNATURE & TITLE OF BANK REPRESENTATIVE PHONE NUMBER00FINANCIAL INSTITUTION INFORMATIONBANK NAME:__________________________________________________________________BANK ADDRESS:_______________________________________________________________(9) DIGIT ROUTING NUMBER:___________________________________________________DEPOSITOR ACCOUNT NAME:__________________________________________________DEPOSITOR ACCOUNT NUMBER:_______________________________________________TYPE OF ACCOUNT: □ CHECKING □ SAVINGS__________________________________________________ (______)_______________SIGNATURE & TITLE OF BANK REPRESENTATIVE PHONE NUMBER12555942105308Please complete three (3) copies of this form with ORIGINAL signatures: Retain one copy for vendor recordsFinancial Institution should retain one copyReturn one copy to the Finance Office:Attn: Kim Rivenskrivens@1030 15th Street, NW, Suite 1100 West Washington, DC 2000500Please complete three (3) copies of this form with ORIGINAL signatures: Retain one copy for vendor recordsFinancial Institution should retain one copyReturn one copy to the Finance Office:Attn: Kim Rivenskrivens@1030 15th Street, NW, Suite 1100 West Washington, DC 20005 ................
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