ACH DIRECT PAYMENT AUTHORIZATION
CITY OF MARCO
ISLAND
(239)
389-5008
Vendor #
PLEASE CHECK ONE: NEW CHANGE CANCEL
New: In addition to completing Form W-9 also attach one of the following:
Voided check with name imprinted (no starter checks)
Bank letter or specifications sheet (the signature of your local bank representative must be included)
NAME OF PAYEE OR
VENDOR:
Last
First Middle
PAYEE
ADDRESS:
Street
City State Zip
PAYEE
PHONE
#:
E-MAIL:
ACCOUNT INFORMATION: (complete only for new requests or changes)
TYPE OF ACCOUNT (check one only) Checking Account Savings Account
Your
Financial
Institution’s
Routing
Number:
Your
Account
Number:
Financial
Institution
Name:
Address:
Phone:
City:
State:
Zip:
AUTHORIZATION: (check appropriate line)
I hereby authorize the City of Marco Island to provide for direct payment of any invoice or reimbursement due to me
into the above designated account.
If at any time the amount of payment so deposited exceeds the amount of payment actually due and payable to me, I
hereby authorize the City of Marco Island at its discretion to either withhold a sum equal to the overpayment from future
payments or recover such overpayment from the above-designated account.
If any action taken by me results in non-acceptance of a direct payment by the designated financial institution, I
understand that the City of Marco Island assumes no responsibility for processing a supplemental payment until the
amount of the non-accepted deposit is returned to the City of Marco Island by the financial institution.
I hereby cancel my ACH Direct Payment authorization.
Signature Date
All City forms can be downloaded from our website
http://www.cityofmarcoisland.com
click to sign
signature
click to edit
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