Type of authorization
(select one only):
NEW: Enter all banking information requested below and submit this form. (Complete lines 1-12 and 16-22)
Note: Student refunds, Lottery payments, DORS payments, Renters tax credits, and Restitution payments are NOT eligible for ACH.
CHANGE: Complete this form by entering changes to the financial institution, account number, or type of account; and submit the completed
form. Do not close your old bank account until electronic payments are received in your new account. (Complete all lines)
CANCELLATION (Revocation): You may cancel (revoke) your prior Authorization by checking this box and completing and submitting this
form. (Complete lines 1-7, 13-15 and 17-22)
Please complete all sections of this Enrollment Form and attach either a voided check OR a letter signed by your bank representative,
confirming account name, account number, and ABA routing number for ACH payments. Starter checks or counter checks are NOT
acceptable. Online credit cards are NOT eligible for ACH transfer.
Send completed form and documentation to: State of Maryland, Comptroller of Maryland, ACH Registration, General Accounting Division, Room
205, P.O. Box 746, Annapolis, Maryland 21404-0746 or fax the form to 410-974-2309. If you have any questions, contact the General Accounting
Division at 410-260-7813, option 7 or toll free at 888-784-0144, option 7.
Please type or print legibly.
PAYEE INFORMATION
☐
☐
Federal Employer No.(FEIN)
6. Contact Name and Title
7. Daytime Telephone Number
OLD BANK ACCOUNT INFORMATION – Complete 13-15
8. Financial Institution Name
13. Financial Institution Name
15. Account Number for Deposit of Electronic Funds Transfer
11. Account Type (Select one only)
☐
☐
12. Financial Institution Telephone Number
16. Level of Detail on Bank Statement Requested (select one only):
☐ Standard format – CCD+ (DEFAULT) ☐ Detailed format - CTX* (multiple detail lines) ☐ Detailed format - EDI* (full detail)
Example: “State of Maryland” “State of Maryland and Invoice Information” “State of Maryland and
Invoice Information”
*Note: You must contact your bank to receive these detailed formats. There may be a charge to you by your bank for detailed formats.
I hereby certify that I am authorized to make the representations contained in this paragraph. I authorize the Comptroller and the Treasurer of
Maryland to register the payee for automated clearing house (ACH) using the information contained in this registration form. I agree to receive all
vendor payments from the State of Maryland by electronic funds transfer according to the terms of the ACH program. I agree to return to the State of
Maryland any ACH payment incorrectly disbursed by the State of Maryland. I agree to hold harmless the State of Maryland and its agencies and
departments for any delays or errors caused by inaccurate or outdated registration information or by the financial institution listed above.
17. Print or Type Name of Payee or Payee’s Authorized Signatory
18. Title of Authorized Signatory
19. Signature of Payee or Payee’s Authorized Signatory
21. Signature of Secondary Signatory(s) – if applicable
ADMINISTRATIVE USE ONLY
GAD Input By: ____________________________________ STO Input By: _______________________________________
GAD Reviewed By: ________________________________ STO Reviewed By: ___________________________________
COT/GAD X-10
(Rev 9/20)
Page 1 of 2
TATE OF
ARYLAND
ACH/DIRECT DEPOSIT
A
UTHORIZATION FOR VENDOR PAYMENTS
