Edi Payment Agreement For Grant And Locality Payments Page 2
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3AGENCY, GRANTEE, LOCALITY, and NON-STATE AGENCY
ELECTRONIC PAYMENT INFORMATION FORM
Agency, Grantee, Locality, or Non-State Agency Information:
Name ___________________________________________________________________________
(THIS MUST BE THE NAME REGISTERED WITH THE IRS FOR THE TAXPAYER ID)
Check one: Locality ____
Grantee _____
State Agency _____
Non-state agency _____
Is another company fiscal agent for your organization?
Yes ______
No ______
Purpose of Account (General, Utilities, Education, Etc.) _________________________________
Taxpayer ID Number (include EDI suffix if pre-assigned)_________________________________
Mailing Address (Street or P.O. Box)__________________________________________________
(City)_________________________(State)_______(Zip Code)___________________
Contact Person ________________________________________ E-mail_____________________
Area Code/Telephone No. (include extension) _________________________________________
Payment Format Desired (Required – must select one):
CCD+ ____
CTX ____
Fax Telephone No. __________________________________________
Bank Information:
Name of Bank _________________________________________________________________
Address of Bank (Street or P.O. Box)_____________________________________________
(City)_____________________(State)_______(Zip Code)______________________________
Check one:
Checking ____________
Savings __________
ACH Transit Routing Number for Bank (9 digits) ____________________________________
Bank Account Number (ACH) ___________________________________
(If your bank merged
in the last year, please confirm the Transit Routing Number and the Bank Account Number with them
before submitting this form.)
Bank Contact Name____________________________________ E-mail_____________________
Bank Area Code & Telephone Number ____________________________
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