Authorization Agreement for ACH Credits
Enrollment Form
Dear Valued Vendor:
Lee County is now offering Automated Deposits (ACH Credits) to expedite your payment(s). If you choose to
participate in the Automated Deposit Program, you will need to complete the Authorization Agreement for ACH
Credits Enrollment Form and submit the completed form, along with a cancelled check,(a picture or pdf file of a
cancelled check will be accepted) to Procurement Management. If you wish to be notified of your ACH deposit
details by email, please include a valid email address in the space provided below.
I (We) hereby authorize the Lee County Board of County Commissioners to initiate credit entries and/or
correction entries to the financial institution and account number listed above. It is further agreed that if any
part of the financial information is incorrect on this form your payment will be delayed until the funds are
returned to the County's bank account. If you do not agree with all the above terms and conditions, your ACH
Agreement will not be accepted. Please return this form to:
Lee County BOCC
Attn: Procurement Management
P.O. Box 398
Phone: 239-533-8881 fax 239-485-8383
Fort Myers, FL 33902-0398
All future changes to the Financial Institution Information you have provided to us will require a new
Enrollment Form to be completed.
Depository Bank Name:
City: State:
Zip Code:
Routing Number: Account Number:
Company Name:
Address:
City: State: Zip Code:
Federal Tax ID: Contact Name:
Phone: Fax:
Email Address*:
* Note: Future email address change requests should be sent to APACH@leeclerk.org
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