Supplier Direct Deposit Authorization
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1
2STATE OF TENNESSEE
Mail the ORIGINAL form to the
DEPARTMENT OF FINANCE & ADMINISTRATION
address below. Mark the outside
SUPPLIER DIRECT DEPOSIT AUTHORIZATION
of the envelope “CONFIDENTIAL”.
(NOT WIRE TRANSFERS)
State of Tennessee
Attn: Supplier Maintenance
21st Floor WRS Tennessee Tower
312 Rosa L Parks Ave
Nashville, TN 37243
SECTION 1: TYPE OF REQUEST
New
Change Existing Account: Enter Existing Routing No:
Existing Account No:
SECTION 2: ACCOUNT HOLDER INFORMATION
Name (as shown on your income tax return):
Business Name, if different from above:
Federal Employer Identification Number (FEIN):
or Social Security Number (SSN):
Enter the address that should be associated with the account number::
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Contact Name:
Telephone:
Enter the email address to which the remittance advices should be routed:
Email:
SECTION 3: AUTHORIZATION
Are payments deposited into this account subject to being transferred, in its entirety, to a financial institution outside of the
United States? Yes
No
Account Type: Checking
Savings
Financial Institution Name:
Routing Number:
Account Number:
I authorize my financial institution to verify any information provided on this form with the State of Tennessee. I also authorize the state
to initiate credit entries and to initiate if necessary, debit entries and adjustments for any credit entries in error, to my account indicated
above. This authorization will remain in effect until the state has received written notification of its termination and has adequate time
to act upon the request.
Authorized Signatory Printed Name:
Authorized Signature:
Date:
SECTION 4: FINANCIAL INSTITUTION VERIFICATION
I certify the account and routing numbers in Section 3 are for the above specified account holder and is signed by an
authorized signatory on the account.
Representative
Signature:
Representative Name:
Date:
Title of Representative:
Business Fax Number:
Business Phone Number:
Mailing Address:
City:
State:
Zip Code:
FA-0825 (Rev. 4/16)
RDA SW20
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