PDF STATE OF FLORIDA
STATE OF FLORIDA Division of Treasury
ACH VENDOR/MISCELLANEOUS PAYMENT ENROLLMENT FORM
This form is used for Automated Clearing House (ACH) payments with/without an addendum record that could contain payment related information. Recipients of these payments must bring this information to the attention of the State Treasurer's Office when presenting this form for completion.
REMITTER INFORMATION
COMPANY/REMITTER NAME:
ADDRESS:
CONTACT PERSON NAME & EMAIL ADDRESS:
ACH FORMAT:
CCD+ CTX PPD OTHER
TELEPHONE NUMBER:
ADDITIONAL INFORMATION:
MyFloridaMarketPlace Vendor Usage Fee:
NAME ADDRESS:
PAYEE/COMPANY INFORMATION
Department of Management Services
SSN OR TAXPAYER ID NO:
59-3458983
4050 Esplanade Way, Suite 280
*AGENCY LOCATION/ID= CODE: (15 digits max.)
7200000
Tallahassee FL, 32399-0950
CONTACT PERSON NAME:
Assiya Underwood Bureau of Financial Management Services
SIGNATURE AND TITLE OF AUTHORIZED OFFICIAL:
TELEPHONE NUMBER:
(850) 487-0950
DATE:
*THIS PAYMENT MUST INCLUDE THE "AGENCY LOCATION/ID= CODE" IN FIELD "7" OF THE DETAIL RECORD WHEN SETTING UP PAYMENT. FAILURE TO PROVIDE THE REQUESTED INFORMATION MAY DELAY OR PREVENT THE RECEIPT OF PAYMENT.
FINANCIAL INSTITUTION INFORMATION
NAME:
Wells Fargo
ADDRESS:
1 Independent Drive
Jacksonville, Florida 32202
NINE-DIGIT ROUTING TRANSIT NUMBER:
121000248
DEPOSITOR ACCOUNT TITLE:
State of Florida, Department of Financial Services
DEPOSITOR ACCOUNT NUMBER:
4859859712
TYPE OF ACCOUNT:
X CHECKING
SAVINGS
LOCKBOX
LOCKBOX NUMBER:
FINANCIAL INSTITUTION APPROVAL INFORMATION
SIGNATURE AND TITLE OF FINANCIAL INSTITUTION OFFICIAL:
DATE:
Instructions to pay your MFMP transaction fee via ACH bank transfer
Complete this form Email your completed form directly to the Florida Department of Management Services (DMS) at
acctsrec@dms. DMS will review your ACH Enrollment Form and forward it to the State Treasury to create an
account Please allow 7 to 14 business days for the process to be completed Upon completion, initiate payment through your bank and include the word/phrase
"MyFloridaMarketPlace" or "MFMP" in the description of the payment Submit a Payment Advice to acctsrec@dms. alerting DMS of the amount and date of
the MFMP electronic payment For questions regarding the status of your request, please email acctsrec@dms.
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