Electronic Funds Transfer Authorization Form - Los Alamos National Laboratory printable pdf download

Electronic Funds Transfer Authorization Form - Los Alamos National Laboratory

Internal Use Only

Electronic Funds Transfer Authorization Form

I, an authorized signer on the below account, hereby authorize Los Alamos National Laboratory, hereinafter called the Laboratory, to

originate Automated Clearinghouse (ACH) credits for invoice payments (vendors), travel reimbursements, small purchase reimbursements

and royalty payments (employees). I further authorize the Laboratory to originate ACH debits to this account but only in the event that the

Laboratory issued an incorrect or duplicate ACH credit to this account. The Laboratory will notify you by telephone in advance of

originating an ACH debit to this account.

Return completed form to:

Treasury Dept.,

Los Alamos National Laboratory

P.O. Box 1663, MS P231,

Los Alamos, NM 87545

Ph: (505) 667-4090, cashiers@lanl.gov

Financial Institution Information

Financial Institution:

You may only set up one bank account for Electronic Fund Payments

Checking

Savings

Cancel (check only)

Change

ABA # (Must Be 9 Digits):

Account #:

FOR CHECKING ACCOUNT AUTHORIZATION ATTACH A VOIDED CHECK HERE OR ATTACH A LETTER OF

BANKING INFORMATION CONFIRMATION FROM YOUR BANK.

THIS FORM WILL NOT BE PROCESSED WITHOUT A

VOIDED CHECK OR CONFIRMATION LETTER

VOID

Authorization Information

E-mail Address (for payment notifications):

Printed Name:

Telephone:

Authorized Signature:

Date:

Vendor Information

Company Name or DBA:

Employee Z#/Vendor#

Address:

City/State/Zip:

Please allow 10 days for processing additions or changes. Separate forms must be submitted for additions or cancellations. This form is to

remain in effect until the Laboratory has received written notification from an authorized representative of its termination in such time to

afford the Laboratory and the Financial Institution a reasonable opportunity to act.

An Equal Opportunity Employer / Operated by Los Alamos National Security LLC for DOE/NNSA

Electronic Funds Transfer Authorization Form - Los Alamos National Laboratory