Fillable ACH/EFT APPLICATION NEW SECTION A: TO BE COMPLETED (City of Wichita)

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ACH/EFT APPLICATION NEW SECTION A: TO BE COMPLETED (City of Wichita)

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The ACH/EFT APPLICATION NEW SECTION A: TO BE COMPLETED (City of Wichita) form is 1 page long and contains:

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  • 11 check-boxes
  • 27 other fields

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File type: PDF

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(INCLUDING STATE EMPLOYEE) INSTRUCTIONS ON REVERSE SIDE
TAXPAYER ID TYPE (CHECK ONE)
VENDOR NAME (30 CHARACTERS MAXIMUM)
SECTION B: TO BE COMPLETED BY STATE EMPLOYEE ONLY (OTHER VENDOR SKIP THIS SECTION)
EMAIL ADDRE
SS
HOME ADDRESS
CITY
STATE
ZIP CODE
C:
D: FINANCIAL INSTITUTION CERTIFICATION
SECTION
E: VENDOR AUTHORIZATION
institution named above, and to credit the sam
and effect until the State of Missouri, Office of Administration has received written notification
SECTION F:
STATE AGENCY USE ONLY
SECTION E: MAILING INSTRUCTIONS
SECTION
G: OFFICE OF ADMINISTRATION USE ONLY
ACH/EFT APPLICATION
SECTION A: TO BE COMPLETED BY SUBMITTING VENDOR -
- INSTRUCTIONS ON REVERSE SIDE
DESCRIPTION
NEW
CHANGE
CANCEL
TAXPAYER ID NUMBER VENDOR NUMBER, if known
2 = SSN
VENDOR/PAYEE NAME
VENDOR ADDRESS
LEGAL NAME OF ENTITY OR INDIVIDUAL
TELEPHONE NUMBER WITH AREA CODE
CITY
STATE ZIP CODE
VENDOR CONTACT NAME 1: PHONE NUMBER
FAX NUMBER
VENDOR CONTACT NAME 2: PHONE NUMBER
FAX NUMBER
SECTION B: TO BE COMPLETED BY SUBMITTING VENDOR
FINANCIAL INSTITUTION NAME
IF CHANGE, PLEASE INDICATE PREVIOUS FINANCIAL INSTITUTION NAME
FINANCIAL INSTITUTION AD
DRESS
FINANCIAL INSTITUTION TELEPHONE NUMBER
CITY
STATE ZIP CODE
DEPOSITOR ABA ROUTING NUMBER
IF CHANGE, PLEASE INDICATE PREVIOUS ABA ROUTING NUMBER
DEPOSITOR ACCOUNT NUMBER
IF CHANGE, PLEASE INDICATE PREVIOUS ACCOUNT NUMBER
DEPOSITOR ACCOUNT TYPE (CHECK ONE) INCLUDED WITH APPLICATION (CHECK ONE)
SAVINGS
CHECKING
VOIDED CHECK BANK LETTER
SECTION C: VENDOR AUTHORIZATION
I hereby authorize the City of Wichita, Finance Department and the above named financial institution to initiate
electronic funds transfers (EFT) into the savings/checking account listed above.
I
her
eby canc
el my ACH/EFT authorization.
AUTHORIZED VENDOR/REPRESENTATIVE (Signature)
DATE
ACH/EFT SET UP BY: DATE:
1= FEIN
The City of Wichita must be notified of any bank account changes.
Failure to notify the City of such changes may result in your payment being delayed.
SECTION D:
RETURN INSTRUCTIONS
Mail to: City of Wichita, Finance Department, 455 N. Main, 12th Floor, Wichita, KS 67202
Fax to: (316) 219-6308
Email to: vendor@wichita.gov
The EFT authorization process may take 1-2 weeks before deposits begin. Please see reverse side for details.
SECTION E:
ACCOUNTING USE ONLY
NOTES:
RESET
ACH/EFT APPLICATION INSTRUCTIONS
Fill in the appropriate boxes as described below
SECTION A: TO BE COMPLETED BY SUBMITTING VENDOR
DESCRIPTION
Check the appropriate box for this submission
TAXPAYER ID TYPE
Check 1 if your taxpayer ID is a Federal Employers Identification number (FEIN) or 2 if your taxpayer ID is a Social Security Number (SSN)
TAXPAYER ID NUMBER
Enter the FEIN or SSN associated with the legal name of the entity or individual
VENDOR NUMBER
If known, enter the vendor number assigned to your business by the City of Wichita
VENDOR NAME
Enter the name
of the entity or individual:
Individual - Enter your name (Last Name, First Name and Middle Initial)
Sole Proprietor - Enter name of Business
Corporation - Enter your Doing Business As (DBA) name
Other - Enter your entity's name
LEGAL ENTITY NAME
Enter Legal Name of Entity or Individual as filed with IRS:
Individual - Enter your name (Last Name, First Name and Middle Initial)
Sole Proprietor - Enter owner's name (Last Name, First Name and Middle Initial)
Corporation - Enter your name as it appears on the charter or other legal documentation as filed with the IRS
Other - Enter your entity's name as filed with the IRS
ADDRESS
Enter your mailing address
TELEPHONE NUMBER
Enter your t
elephone number with area code
CITY, STATE, ZIP CODE
Enter your city, state and zip code for the mailing address
SECTION B: TO BE COMPLETED BY SUBMITTING VENDOR
FINANCIAL
INSTITUTION NAME, ADDRESS, CITY, STATE, ZIP CODE, PHONE NUMBER
Enter information provided by your bank
NOTE: If this is a request for a "CHANGE" please provide your previous financial institution name in the space provided
DEPOSITOR ABA ROUTING NUMBER
Enter your financial institution'
s routing number
NOTE: If this is a request for a "CHANGE" please provide your previous routing number in the space provided
DEPOSITOR ACCOUNT NUMBER
Enter your account number
NOTE: If this is a request for a "CHANGE" please provide your previous account number in the space provided
DEPOSITOR ACCOUNT TYPE
Please select type of account (savings or checking)
SUPPORTING DOCUMENTATION
Voided check or bank letter is required to be attached with your application
SECTION C: VENDOR AUTHORIZATION
VENDOR AUTHORIZATION
Must be signed by the vendor or an authorized representative before application can be processed.
SECTION D
: MAILING INSTRUCTIONS
Three ways to r
eturn completed form:
Mail to:
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GENERAL INSTRUCTIONS
If all the necessary sections on this form are not completed, the application will not be processed.
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ACHEFT APPLICATION NEW SECTION A: TO BE COMPLETED (City of Wichita)

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Completed 17 July 2020

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