Ach Vendor Payment Authorization Form - Southern California Association Of Governments
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1ACH VENDOR PAYMENT AUTHORIZATION FORM
This form is used for Automated Clearing House (ACH) payments. The information being collected on this
form will be used by the Southern California Association of Governments (SCAG) to transmit payment data,
by electronic means, to a vendor’s financial institution. Failure to provide the requested information may delay
or prevent the receipt of payment through ACH Payment System. Recipients of the payments should bring
this information to the attention of their financial institution when presenting this form for completion.
Recipients should also request to be notified immediately regarding any change occurring at the
financial institution that may delay or prevent the receipt of scheduled payments.
This Section to be completed by Vendor
VENDOR INFORMATION
NAME:____________________________________________________________
ADDRESS:_________________________________________________________
CONTACT NAME:__________________________________________________
FEDERAL I.D.#:____________________________________________________
A/R EMAIL ADDRESS:______________________________________________
I, the undersigned, authorize SCAG to deposit funds directly to the account indicated
above and to correct any errors which may occur from the transactions. I also authorize the
financial institution named below to post these transactions to that account. This
authorization will remain in force until SCAG receives written notice of cancellation from
‘
me and SCAG has reasonable time to act upon it.
__________________________________________________________________
AUTHORIZED SIGNATURE / PRINT NAME / TITLE
This Section to be completed by Financial Institution (Bank)
FINANCIAL INSTITUTION INFORMATION
NAME:___________________________________________________________
ADDRESS:________________________________________________________
ACH COORDINATOR NAME:_______________________________________
(9) DIGIT ROUTING NUMBER:______________________________________
DEPOSITOR ACCOUNT TITLE:______________________________________
DEPOSITOR ACCOUNT NUMBER:___________________________________
.
TYPE OF ACCOUNT: CHECKING SAVINGS
___________________________________________ (______)_______________
SIGNATURE & TITLE OF REPRESENTATIVE PHONE NUMBER
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