Form Fa-0825 - Ach (Automated Clearing House) Credits (Not Wire Transfers) 1996 printable pdf download

STATE OF TENNESSEE

DEPARTMENT OF FINANCE AND ADMINISTRATION

ACH (AUTOMATED CLEARING HOUSE) CREDITS (Not Wire Transfers)

_________________________________________________________________________________

NAME

_____________________________________

Federal Identification Number or Social Security Number

(under which you are doing business with the State)

I (We) hereby authorize the State of Tennessee, hereafter called the STATE, to initiate credit entries to my (our) (select type of

account)_______ CHECKING or _______ SAVINGS account indicated below and the depository named below, hereinafter called

DEPOSITORY, to credit the same to such account.

This authority is to remain in full force and effect until the STATE has received written notification from me (or

one of us) of its termination in such time and in such manner as to afford the STATE and DEPOSITORY a reasonable

opportunity to act on it.

****************************************************************************************************

Have you ever received payments from the State through ACH? _______ (Yes or No). If yes, do you intend for this account

information to replace existing account information currently used by the State? ______ (Yes or No). If yes, please specify

account that should be changed: ABA No. _______________________ Account No. ____________________________. Is

this authorization only for certain types of payments? ________ (Yes or No). If yes, please indicate types:

_______________________________________________________________________

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Many banking institutions use different numbers for ACH. Please call your bank for verification of ACH transit and account

number.

Bank official contacted: _____________________________________ Phone No. _________________________

****************************************************************************************************

DEPOSITORY/BANK NAME _____________________________BRANCH ____________________________

CITY ____________________________________________________STATE ___________________________

ACH TRANSIT / ABA NO. _____________________________ACCOUNT NO. _________________________

NAME(S) __________________________________________________________________________________

(Please print names of authorized account signatory)

DATE _______________________SIGNED X ______________________SIGNED X _____________________

PLEASE ATTACH A VOIDED CHECK (OR FOR SAVINGS ACCOUNTS, A DEPOSIT SLIP):

PLEASE INDICIATE ADDRESS TO WHICH YOU WOULD LIKE YOUR REMITTANCE ADVICES

ROUTED WHEN PAYMENTS ARE PROCESSED:

____________________________________________________________________________________________

Contact name:

_____________________________________________________________________________

Telephone No.: ______________________________________________________________

FOR STATE USE ONLY:

CONTACT AGENCY – _______________________

CONTACT PERSON _ _______________________

PHONE NUMBER

_ _______________________

FA-0825 (Rev. 4/96)

Form Fa-0825 - Ach (Automated Clearing House) Credits (Not Wire Transfers) 1996