Electronic Funds Transfer Authorization
(via Automated Clearing House) Revised 2/8/2018
SECTION 1. Enrollment Type
Please select the box that indicates the enrollment action.
If this is a change or a request to add to an existing vendor, please indicate the vendor number:
SECTION 2. Remittance E-Mail Notification
Please provide one or more Accounts Receivable e-mail addresses where ACH remittance information should be sent:
SECTION 3. Account Information
Name of Individual/Business:
Name of Financial Institution:
Financial Institution Address (Number and Street):
Depositor Account Number:
Type of Account:
Nine-Digit Routing Number:
Re-enter Routing Number:
1. Select the appropriate action:
Authorize direct deposit of payments due the entity named in Section 3
Cancel direct deposit for the entity named in Section 3
2. Provide certification information:
I certify that the entire amounts authorized to be received by this account are not subject to be transferred to a foreign
bank account. I acknowledge that if this box is not selected, the Judicial Council of California (JCC) will issue all
payments by check only.
If I transfer money from this account to an offshore bank, I will cancel this authorization and notify the JCC. This authorization
remains in full force and effect until the JCC receives written notification from the entity of its termination in such manner as to afford
the JCC and financial institution a reasonable opportunity to act on it, or until the JCC terminates the agreement. This authorization
and any future notifications must be sent to one of the contacts listed in Section 5:
Authorized Signature of Entity Named in Section 3:
×_____________________________________________________________________
Signature
Provide the last 4-digits the taxpayer identification number associated with this vendor:
Provide an e-mail address below where we can contact you to verify your request:
SECTION 5. General Instructions
1. To enroll for direct deposit of payments from the Superior Courts of California or change, certify, or cancel your existing
direct deposit, complete sections 1, 2, 3 and 4 of this form (all information must be legible). Please include an e-mail address
in section 4, as we will contact you to verify your request.
2. To obtain routing number or account number information, contact your financial institution.
3. Your direct deposit will continue to be deposited into your designated account at your financial institution until the JCC is
notified that you wish to re-designate your account and/or your financial institution. To re-designate, complete and submit a
new form with the new information. Do not close your old account until your first payment is deposited into your newly
designated account and/or financial institution.
4. Submit this form to your court representative who will forward it to the Judicial Council of California.
click to sign
signature
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