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Indicate the type of authorization being requested:
New Payment Authorization Request
Payment Authorization Change
Payment Authorization Termination
Vendor Name
Vendor Remittance Address
City
Telephone Number Email Address (Required)
Tax Identification Number Contact Person
Bank Name
Bank Address
City
Type of Bank Account:
State Zip Code
State Zip Code
Checking (Provide a voided check or bank letter that includes your routing/transit and bank account number)
Savings (Provide a bank letter that includes your routing/transit and bank account number)
Authorized Representative Signature:
Printed Name:
Date
ACH AUTHORIZATION FORM
Note: This is a fillable PDF form. Fill and use electronic signature if possible in lieu of printing and scanning.
VIRGINIA HOUSING USE ONLY
I have contacted the vendor and confirmed the action being requested should be completed.
Virginia Housing Associate Name (Print) Signature Date
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Title
click to sign
signature
click to edit
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click to sign
signature
click to edit
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