CITY OF PATASKALA, OHIO
ACCOUNTS PAYABLE
ACH PAYMENT AUTHORIZATION
Vendor Name:
Contact Name:
Contact Phone #:
Email Address:
Banking Institution Name:
Bank Account Type: □ Checking □ Savings
ABA Routing/Transit #:
Bank Account #:
The vendor, as named above, desires for the City of Pataskala to remit payments on the vendor’s
outstanding invoices via ACH. I hereby authorize the City to electronically credit our account for
such payments, and if necessary, electronically debit our account to correct erroneous debts.
This authorization shall remain in force until, and unless, revoked by the company in writing.
We understand that the City requires at least 5 business days prior notice in order to cancel this
authorization. Additionally, we recognize that it is the responsibility of the vendor, not the City,
to ensure that any changes to the vendor’s ACH information is timely communicated to the City’s
accounts payable department.
Authorized Signature Date
Official Use Only:
Vendor #: System Entry Date:
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signature
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