Ach Payment Enrollment Form
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1
2501 Crescent Street
New Haven, CT 06515-1355
ACH Payment Enrollment Form
See Page 2 for Terms and Conditions.
Type of Action (Please Check One)
Retain a copy of this agreement for your records.
New
Change
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Block 1 - INDIVIDUAL/COMPANY INFORMATION
Company
Individual
I am currently a State employee
FEIN#: _____- __________________
(Federal Employee Identification Number)
Banner ID:__________________
(Banner ID Required for SCSU Students/Staff)
Name: _______________________________
Business/Organization Name
Name:_______________________________
Address: _____________________________
Mailing Street Address
_____________________________
Address: _____________________________
City, State and ZIP Code
Mailing Street Address
_____________________________
Name: _______________________________
City, State and ZIP Code
Authorized Representative
Title: ________________________________
Phone _______________________________
Phone _______________________________
Block 2 - FINANCIAL INSTITUTION INFORMATION
Institution Name: _____________________________________________
Institution Account Number: ____________________________________
Nine-Digit Routing Number: _____________________________________
Your financial institution routing number can be found on your check, it is the first nine digits on the lower left of your
check followed by your institution account number and check number.
Type of Account:
Checking
Savings
Block 3 - NOTIFICATION METHOD
Notification of your deposit confirmation will be sent via e-mail. If you do not provide an e-mail
address your deposit confirmation will be mailed to the address listed in Block 1.
Email Address: ___________________________________________
By signing below, I acknowledge that I have read, understand and agree to the Terms
and Conditions on Page 2
Signature: ___________________________________ Date: ________________
If you have any questions concerning ACH transactions, please contact SCSU Accounts
Payable at 203-392-6844
ACCOUNTS PAYABLE USE ONLY
Updated in Banner
Processed by: ____________
Date:___________
Page 1
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