ELECTRONIC PAYMENT INFORMATION



STUDENT ACH PAYMENT INFORMATION

For United States Banks Only

|STUDENT PERSONAL INFORMATION |

|Student Name | |Student ID Number | |

| | |

|Address |Street | |

|(Home mailing address) | | |

| |City | |State | |Zip Code | |

|Telephone # | | |

|E-mail Address | | |

Top of Form

|US ACH BANK INFORMATION (Your local branch contact) |

|Bank Name | |

|Address |Street | |

| |City | |State | |Zip Code | |

|Bank Contact |Name(s) | |

| |Telephone # | |Fax # | |

|ACH Routing # | |Note: This must be for use with ACH transactions and may be different than a |

|(full nine digits) | |fed wire routing number. |

|Bank Account # | |

|Account Type |Checking |[pic] |

| |Savings (not currently available) | |

Bottom of Form

I hereby authorize initiation of direct deposits of accounts payable disbursements into the account specified above and approve reversal of any such funds if deposit is submitted in error.

Signature:

Print Name:

Date:

Please note that no formal ACH payment notifications are generated by our current payables system. You should refer to your reimbursement request copies for explanation of payments.

Please return this form to and contact Disbursement Services at dspayments@vanderbilt.edu for any questions or concerns about this form or the ACH payment process.

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