Ach Authorization Form - West Virginia State Treasurer'S Office (Page 2 of 2) in pdf

Ach Authorization Form - West Virginia State Treasurer'S Office Page 2

West Virginia State Treasurer’s Office

John D. Perdue, Treasurer

Instructions for Completing the ACH Authorization Form

Originator Instructions

1. Please complete all areas under the header of Payer Information

2. Your ACH processor can tell you what ACH format will be used in the file transmission. The most common

formats that are received by the West Virginia State Treasury are PPD, CCD, CCD+, and CTX.

3. If there will be an EDI file, please indicate which dataset your company uses.

4. Please use the number indicated in the Payee’s FEIN number field as the Identification Number.

5. The Agency Name should be indicated in the “Receiving Company Name” field.

6. The Transaction Code is 22.

7. If it is possible, please prenote the transaction.

Agency Instructions

1. Please mail or fax a copy of the ACH Authorization Form to any company or individual who wishes to pay you

electronically. This payment must be made for state revenue. A definition of state revenue can be found in

Chapter 12 of the State Code.

2. After the company or individual completes the top of the form, please complete the PAYEE section and mail or

fax the form to the West Virginia State Treasury at (304) 340-1509. The form will be reviewed, and the Treasury

Information section will be completed and mailed back to your agency. It is the responsibility of the Agency to

send the completed form back to the company or individual.

3. For multiple locations within your agency, you may add digits to your FEIN number. You may use a total of 15

characters including dashes and spaces.

4. Please be as specific as possible in the Agency Name. For Example, instead of using “Alcohol Beverage Control

Commission”, it is much more informative to use “ABCC-Warehouse Receipts”. You may use a total of 22

characters including spaces and dashes.

5. There will need to be a WVFIMS deposit processed in the exact amount of each deposit your agency

receives. For data entry purposes, the depositing location is 00875, and the ticket number is 00875-000. If

you know the amount of the deposit, the FIMS deposit coversheet may be entered prior to the receipt of

the funds. It will be held by our staff until the amount of the deposit posts to the bank account. At that

time, it will be approved by our staff and completed by the WV State Auditor’s Office. If you need to be

notified after money is received, please provide a backup contact and an e-mail address. Please note that

the FIMS documents that relate to electronic deposits are required to be submitted to the State

Treasurer’s Office within 24 hours of the receipt of the funds.

Ach Authorization Form - West Virginia State Treasurer'S Office Page 2