Authorization For Electronic Deposit Of Vendor Payment
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AUTHORIZATION FOR ELECTRONIC DEPOSIT OF VENDOR PAYMENT
(
Please print or type all information)
Enter the following vendor information:
1.
VENDOR INFORMATION
FEIN: __________________________________
Sfx (State useonly) _____
Vendor Name: _______________________________________________________________________
TIN Name: _________________________________________________________________________
Street:: ______________________________________________________________________________
City: _____________________________ State: ____________________ Zip: __________________
Telephone#: ________________________ Contact: ________________________________________
Complete Section A with the deposit information for the baseline and growth funds received from the
2.
gross revenues and excise tax fund.
SECTION A
Financial Institution Information
Bank Name: __________________________________________________________________________
Branch: ______________________________________________________________________________
or correspondent bank (if applicable)
City: _____________________________ State: ____________________ Zip: __________________
Transit/ABA No. ______________________________
Account Number: _____________________________________________________________
Account Type (select one):
Checking Account
Savings Account
3.
Complete Section B with the deposit information for the local property tax distribution.
Check here and do not complete Section B if account information is the same as Section A.
SECTION B
Financial Institution Information
Bank Name: __________________________________________________________________________
Branch: ______________________________________________________________________________
or correspondent bank (if applicable)
City: _____________________________ State: ____________________ Zip: __________________
Transit/ABA No. ______________________________
Account Number: _____________________________________________________________
Account Type (select one):
Checking Account
Savings Account
SEE PAGE 2
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