Ach Authorization Form - West Virginia State Treasurer'S Office printable pdf download

West Virginia State Treasurer’s Office

John D. Perdue, Treasurer

ACH Authorization Form

This form is used to authorize payments to West Virginia State Agencies by electronic means. These payments are to

be made through the Automated Clearing House, and may contain addenda records.

The West Virginia State Treasurer’s Office abides by the operating rules of NACHA (National Automated Clearing

House Association). Copies of the rules can be purchased at

Information provided on this form is PRIVATE. Any unauthorized use of this information is a violation of law.

PAYER INFORMATION

Name____________________________________________________FEIN or SSN_________________________

Address______________________________________________________________________________________

_____________________________________________________________________________________

Contact Person Name ______________________________________Phone _______________________________

ACH Format: _____________ Reason for Payment:___________________________________________________

PAYEE/AGENCY INFORMATION

Agency Name_____________________________________________FEIN _______________________________

Address______________________________________________________________________________________

_____________________________________________________________________________________

Contact Person Name ______________________________________Phone _______________________________

Title of Contact Person_____________________________________Fax Number___________________________

Signature and Title of Authorized Person____________________________________________________________

Description of payment__________________________________________________________________________

TREASURY INFORMATION

The West Virginia State Treasurer’s Office hereby authorizes the payer named above (hereafter called Originator) to

initiate credit entries into the account indicated herein. The rights and obligations of the Originator concerning the

entry shall be governed by and construed in accordance with the laws of the State of West Virginia. This authority is

to remain in full force and effect until either party receives written notice of its termination in such time and in such

manner as to afford a reasonable opportunity to act on it.

Name of Financial Institution _____________________________________________________________________

Address of Financial Institution____________________________________________________________________

____________________________________________________________________

Routing Transit Number __________________________ Account Number _______________________________

Account Title __________________________________________________________________________________

Signature of Authorized Official ___________________________________________________________________

Phone Number of Authorized Official_________________________________Date __________________________

Ach Authorization Form - West Virginia State Treasurer'S Office