Fillable HW 04 Complete Snow Packet PDF (Town of Brookhaven)

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HW 04 Complete Snow Packet PDF (Town of Brookhaven)

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Single Vendor or Business Checklist of Items to be Submitted
ALL VENDORS:
• Certificate of Insurance, naming the Town of Brookhaven as Certificate Holder. Including proof of
snow plow coverage (See Insurance Requirements)
• Worker’s Compensation Insurance (if not sole proprietor)
• Copy of current DMV Vehicle Registration
• Employer Affidavit of Compliance Form (must be notarized and submitted at the start of each winter season)
• Truth-in-Nepotism Affidavit (must be notarized and updated if there is a change)
• E-Mail Address / Cell Service Provider / 10 Digit Cell Number (required each winter season)
• Direct Deposit Form (if requested)
• GPS Acknowledgement (required each winter season)
• Snow Vendor Payment Terms and Agreement (required each winter season)
NEW VENDORS: IN ADDITION TO THE ITEMS ABOVE:
• Affidavit of Ownership Form (must be notarized)
• W-9 Form (vendor name must match registration name)
• Copy of current DMV Driver’s License (only for sole proprietor)
• Affidavit – Validity of NYS Driver’s Licenses/Insurance Coverage/Hold Harmless Statement
• Certified Partnership Papers are required if anyone other than the owner will be driving vehicle and
when worker’s compensation insurance is not provided
• Vehicle Information Form (all necessary information must be completed)
PLEA
SE NOTE: WE CANNOT PHOTOCOPY YOUR PAPER WORK.
PLEASE MAKE COPIES OF ALL PAPERWORK PRIOR TO SUBMITTING YOUR PACKET.
You can view the vendor snow process and download the application packet online at
ht
tp://www.brookhavenny.gov /documentcenter/view/112
Or you can pick up an application packet at The Town of Brookhaven Highway Department located at
1140 Old Town Road in Coram; Monday – Friday between 8:00 am & 3:30 pm
Town of Brookhaven
Requirements for Part Time
Snow Removal Work
Highway Department
HW- 04 – Revs. 11/28/18
1140 Old Town Road
Coram, NY 11727-0987
(631) 451-9200 Fax: (631) 732-6257
Long Island, New York
Vendor Name: _____________________________ Phone Number: _________________________ Date: ____________
Town of Brookhaven
Highway Department
INSURANCE REQUIREMENTS
(1) AUTO LIABILITY: For Pick-up Trucks and Dump Trucks
• $100,000 bodily injury each person
• $300,000 bodily injury each occurrence
• $100,000 property damage each occurrence
(2) AUTO LIABILITY: $1,000,000 (Combined Single Limit)
Vehicles needing coverage for all work including snow:
Sweepers Vac-Alls Graders Loaders Orange Peeler
Dozers Cranes Backhoes Excavators Tractor Trailers
(3) GENERAL LIABILITY: $1,000,000 (Combined Single Limit) with Explosion, Collapse and
Underground Hazard
(4) SCHEDULE OF VEHICLE(S): Policy Number, Vehicle Identification Number (VIN) and
Description, including Year, Make, Weight, etc.
(5) CANCELLATION CLAUSE: the company will give the Town of Brookhaven Highway
Department 15-20 days advance written notice by mail of any change or cancellation of said
policy/policies
(6) CERTIFICATE OF INSURANCE:
• must be signed
• must name the Town of Brookhaven Highway Department, 1140 Old Town Road, Coram,
NY 11727 as the certificate holder
• All policies must include a snow plow endorsement that states “Includes Snow Plowing
Operations”
• must state effective and expiration dates
• must be an original copy
(7) CERTIFICATE OF WORKER’S COMPENSATION: is required if vehicle is driven by anyone
other than registered owner
(8) DISABILITY BENEFITS, LIABILITY INSURANCE AND OWNER’S AND
CONTRACTOR’S PROTECTIVE LIABILITY POLICIES original policies are required
***IT IS THE RESPONSIBILITY OF THE INSURED TO SUPPLY THE TOWN WITH UPDATED
CERTIFICATES. SEND ALL CERTIFICATES TO:
TOWN OF BROOKHAVEN HIGHWAY DEPARTMENT
1140 OLD TOWN ROAD, CORAM, NY 11727
Updated 11/28/18
Vehicle Information Form
Name: _________________________________________ Date: _______________
Address: _______________________________________ Phone: ____________________
_______________________________________
TRUCK
LOADER
DOZER/TRACTOR LICENSE PLATE #
SWEEPER
LICENSE PLATE #
ROLLER LICENSE PLATE #
CRANE
PLOW
SPREADER GRADER
LICENSE PLATE #
Town of
Highway
Brookhaven
Department
SIDEWALK CREW
CHAIN SAW BLADE SIZE
EDGER
BLOWER
PUSH MOWER
RIDE-ON MOWER HORSEPOWER
MAKE
YEAR
Town of Brookhaven
Corporation Affidavit of Ownership
This is to certify that I, _______________________________________________ am an officer of the
corporation so named _____________________________________with its principal place of business located
at ___________________________________________________________________.
I further certify that said corporation is the owner of the following equipment:
______________________________________
______________________________________
______________________________________ and that no appointed or elected official* of the Town of
Brookhaven is an owner, co-owner , stock holder or officer, nor will become an owner, co-owner, stock holder
or officer of said company during the rental period.
This affidavit is made to induce the Superintendent of Highways of the Town of Brookhaven to rent such
equipment and said Superintendent relies on the truth of the statements made herein.
_____________________________________
Signature
State of New York )
ss:
County of Suffolk )
On this _________day of _________________, _________ before me, the undersigned, a Notary Public in and
for said State, personally appeared _______________________, personally known to me or proved to me on
the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and
acknowledge to me that he/she executed the same in his/her capacity, and that by signature on the instrument,
the individual executed said instrument.
____________________________
Notary Public, State of New York
*The term official is defined as the Supervisor, Highway Superintendent, Town Clerk, Tax Receiver, Bingo Inspector, any member of
the Town Board, or any member of the Zoning Board, Planning Board, Accessory Apartment Review Board, Board of Assessment
Review, or Board of Ethics.
Town of Brookhaven
Individual Affidavit of Ownership
This is to certify that I, _______________________________________________ am employed by the
Town of Brookhaven as an independent contractor and that I use my own tools and equipment, and do
not hire employees.
__________________________________, being duly sworn depose and says that I am the owner of the
following equipment:
______________________________________
______________________________________
______________________________________ and that no appointed or elected official* of the Town of
Brookhaven is an owner or co-owner of said equipment, nor will become an owner or co-owners of said
equipment during the rental period.
This affidavit is made to induce the Superintendent of Highways of the Town of Brookhaven to rent such
equipment and said Superintendent relies on the truth of the statements made herein.
_____________________________________
Signature
State of New York )
ss:
County of Suffolk )
On this _________day of _________________, _________ before me, the undersigned, a Notary Public in and
for said State, personally appeared _______________________, personally known to me or proved to me on
the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and
acknowledge to me that he/she executed the same in his/her capacity, and that by signature on the instrument,
the individual executed said instrument.
____________________________
Notary Public, State of New York
*The term official is defined as the Supervisor, Highway Superintendent, Town Clerk, Tax Receiver, Bingo Inspector, any member of
the Town Board, or any member of the Zoning Board, Planning Board, Accessory Apartment Review Board, Board of Assessment
Review, or Board of Ethics.
Town of Brookhaven
Employer Affidavit of Compliance with respect to
the Hiring of Employees in Accordance with Federal Law
(Town Code Chapter 7A)
Employer Firm: ________________________________
Project Name (Service): _____________________
I, __________________________________ being duly sworn, depose and state that I am a(n)
Officer Partner Owner Member of the firm.
By submission of this Affidavit and each person signing on behalf of an Employer, including but not limited to
owner, firm, cooperation or entity herby certifies under penalty of perjury, that I affirm of my own knowledge
that the above named person on behalf of the Employer has complied with the requirements of Title 8 of the
United State Code (USC) Section 1324a and any amendments thereto, and that all employees, including non-
citizens and aliens, which include full-time, part-time, temporary or seasonal employees, are authorized to work
in the United States and that said employees, including non-citizens and aliens have provided the required
documents for my review, which appear to be genuine and demonstrate to the best of my knowledge, the
employees are authorized to work in the United States; and that during the term of the contract, agreement or
period of work performed by the Employer, all employees hired or retained shall be authorized to work in the
United State in compliance with Federal Law; and that the Employer will only employ or retain subcontractors /
special consultants who hire or retain employees authorized to work in the United States; and any such
subcontractors / special consultant shall be required to submit an Affidavit demonstrating compliance with
Federal Law regarding the eligibility of employees to work in the United States, and that the subcontractor’s /
special consultant’s employees have submitted the required documents demonstrating compliance with Federal
Law, which said Affidavit shall be submitted to the Town with the Employer’s request for subcontractor /
special consultant approval and at all times required by the Town Code.
_____________________________________
Signature
State of New York )
ss:
County of Suffolk )
On this _________day of _________________, _________ before me, the undersigned, a Notary Public in and
for said State, personally appeared _______________________, personally known to me or proved to me on
the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and
acknowledge to me that he/she executed the same in his/her capacity, and that by signature on the instrument,
the individual executed said instrument.
____________________________
Notary Public, State of New York
Snow and Ice Removal
Town of Brookhaven
Truth in Nepotism Affidavit *
§7A-26-B
Note: Pursuant to Chapter 7A Article III of the Code of the Town of Brookhaven, any contractor or vendor
hired for work exempt under General Municipal Law shall sign a sworn affidavit at least five business days
prior to the commencement of the contract with the Town of Brookhaven, stating whether or not such individual
is a spouse, mother, father, brother, sister, grandfather, grandmother, grandson, granddaughter, step-father, step-
mother, step-sister, step-brother, in-law, aunt, uncle, niece, nephew, first cousin, or spouse of any member of
the contractor or vendor’s immediate family (immediate family also includes a person who is in a spouse-like
relationship to the contractor or vendor) of the following elected and /or appointed officials: Supervisor,
Highway Superintendent, Town Clerk, Tax Receiver, Bingo Inspector, or any members of the Town Board,
Zoning Board, Planning Board, Accessory Apartment Review Board, Board of Assessment Review, or Board of
Ethics.
I, __________________________________ being duly sworn, depose and state that I am neither the
spouse, mother, father, brother, sister, grandfather, grandmother, grandson, granddaughter, step-father, step-
mother, step-sister, step-brother, in-law, aunt, uncle, niece, nephew, first cousin, or spouse of any member of
the contractor or vendor’s immediate family (immediate family also includes a person who is in a spouse-like
relationship to the contractor or vendor) of the following elected and /or appointed officials: Supervisor,
Highway Superintendent, Town Clerk, Tax Receiver, Bingo Inspector, or any members of the Town Board,
Zoning Board, Planning Board, Accessory Apartment Review Board, Board of Assessment Review, or Board of
Ethics.
(If none, so state – NONE)
_____________________________________________________________________________________
I have read the aforesaid section and make this affidavit with the full knowledge that the Town of Brookhaven
is relying on this affidavit. I swear under penalty of perjury that the information contained in this document is
true and correct.
_____________________________________
Signature
State of New York )
ss:
County of Suffolk )
On this _________day of _________________, _________ before me, the undersigned, a Notary Public in and
for said State, personally appeared _______________________, personally known to me or proved to me on
the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and
acknowledge to me that he/she executed the same in his/her capacity, and that by signature on the instrument,
the individual executed said instrument.
____________________________
Notary Public, State of New York
*
For any contractor or vendor hired for work exempt under GML.
Town of Brookhaven
Affidavit of Compliance with Respect to Validity of NYS Driver’s Licenses,
Insurance Coverage and Hold Harmless Statement
Contractor: ________________________________
I, __________________________________ being duly sworn, depose and state that I am a(n)
Officer Partner Owner Member of the firm.
By submission of this Affidavit I certify under penalty of perjury and affirm that I and any drivers in my employ
who will be operating motor vehicles while providing services to the Town of Brookhaven shall have a valid
NYS Driver’s License free of violations or restrictions which would preclude them from driving on the Town’s
behalf. If there is any change to the status of any of license, it is my responsibly to immediately notify the Town
of Brookhaven Highway Department of such change.
I also affirm that it is my obligation to immediately inform the Town of Brookhaven Highway Department of
any insurance coverage changes or cancellations. Failure to properly notify the Town of any changes could
result in the revocation of the contractor’s ability to provide services to the Town.
If while providing services to the Town, I or one of my employees is involved in a motor vehicle accident or
cause any damage to private property, it is my responsibility to immediately file a Suffolk County Police
Department incident report and report the incident to the supervising foreman at the Town of Brookhaven
Highway Department.
The Contractor agrees that it shall defend, indemnify and hold harmless the Town of Brookhaven, its officers,
officials, employees, contractors, agents, and other persons from and against all liabilities, fines, penalties,
actions, damages, claims, demands, judgements, losses, costs, expenses, suits or actions, and reasonable
attorney’s fees arising out of the acts or omission or the negligence of the contractor in connection with the
services provided by said contractor.
_____________________________________
Signature
State of New York )
ss:
County of Suffolk )
On this _________day of _________________, _________ before me, the undersigned, a Notary Public in and
for said State, personally appeared _______________________, personally known to me or proved to me on
the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and
acknowledge to me that he/she executed the same in his/her capacity, and that by signature on the instrument,
the individual executed said instrument.
____________________________
Notary Public, State of New York
1140 Old Town Road, Coram, NY 11727-3728
Phone (631) 451-9200 * Fax (631) 732-6257 * www.brookhavenny.gov
Daniel P. Losquadro
Superintendent of Highways
Dear Vendor:
To improve efficiency, the Highway Department is updating its procedures for snow removal call-
outs. We will be automating our systems through e-mails and texts, and phasing out individual
phone calls.
Your e-mail address, cell service provider and 10-digit cell phone number are required to be on the
snow removal call out list. You must be able to receive text messages through the cell phone
number provided. If this information is not provided, you will not be on the call-out list and will
not be able to provide snow removal services for the Town.
Please neatly print your information on the lines below. It is imperative that we can read all the
information so that it can be accurately entered into our system.
VENDOR’S REGISTRATION NAME: _______________________________________
E-MAIL ADDRESS: ____________________________________________________
CELL PHONE #, 10 DIGITS: ____________________________________________
CELL SERVICE PROVIDER: ____________________________________________
Department
Town of
Brookhaven
Highway
1140 Old Town Road, Coram, NY 11727-3728
Phone (631) 451-9200 * Fax (631) 732-6257 * www.brookhavenny.gov
GLOBAL POSITIONING SYSTEM (GPS) UNIT ACKNOWLEDGEMENT
Snow Removal Vendor Acknowledgement MUST be signed by all vendors.
By signing this form, I agree to the following:
I am responsible for the GPS unit issued to me / my company; I will use it in the manner intended; I
will be responsible for any damage (excluding normal wear and tear); upon request by a Town of
Brookhaven employee, I will return the GPS unit in proper working order (excluding normal wear &
tear); I will replace any GPS unit that is damaged or lost at my expense; and I authorize a deduction
from my claim for payment to cover the replacement cost of any unit that is not returned, for whatever
reason, or is not returned in good working order. The replacement cost for one mobile GPS unit is
$249.
Company/Individual Name: _________________________________________
Signature of Responsible Party: _____________________________________
Printed Name: ____________________________________________________
Date: ___________ Best Contact Number: _____________________________
Daniel P. Losquadro
Superintendent of Highways
Department
Town of
Brookhaven
Highway
Snow Vendor Payment Terms and Agreement
Vendor/Company/Individual hereby authorizes the Town of Brookhaven to utilize the vehicle
Global Positioning System (GPS) provided by the Town of Brookhaven, Highway Department to
validate the date and hour of services that were provided to the Town for snow removal and related
services.
The Town of Brookhaven Highway Foreman is responsible for monitoring the vendor’s/company’s
driver or individual’s work assignments and recording the corresponding work ticket details which
include the type of work performed, the vehicle license plate number, the date, start time, finish time
and total hours worked each day. The equipment operator is required to sign and date the work
ticket at the end of each month, affirming that the hours recorded are accurate for payment. The
Town’s Highway Foreman will validate the work performed, sign and date the work ticket and
submit the work ticket to the Town Highway Department Administration for payment processing.
The Town of Brookhaven Highway Department Administration will review the GPS report for the
vendor’s vehicle and compare the submitted work ticket to the GPS report. If there are any
discrepancies the Town of Brookhaven Highway Department will contact the
vendor/company/individual to reconcile and resolve the discrepancy in a timely manner.
Discrepancies may delay the payment processing time.
If there are no discrepancies, an invoice will be prepared by the Town Highway Department
Administration, signed by the designated Highway Department authorities, and processed for
payment by the Town of Brookhaven Finance Department.
The Town’s policy is to remit payments for verified Snow Vendor Services within sixty (60) days of
submission by the Foreman, if there are no discrepancies. The vendor/company/individual has thirty
(30) days from the issuance of the check or electronic funds transfer to dispute the payment in
writing.
By signing this document, the vendor/company/individual, agrees that the Town of Brookhaven is
hereby authorized to use the GPS equipment to validate the date and hours of driver services for the
payment of services, and all other terms and conditions of this agreement.
____________________________ ___________________________________
Print Name Company Name
__________________________________ ___________________
Vendor/Company/Individual Signature Date
Daniel P. Losquadro
Superintendent of Highways
Department
Town of
Brookhaven
Highway
Form W-9
(Rev. November 2017)
Department of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
a
Go to www.irs.gov/FormW9 for instructions and the latest information.
Give Form to the
requester. Do not
send to the IRS.
Print or type.
See Specific Instructions on page 3.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2 Business name/disregarded entity name, if different from above
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the
following seven boxes.
Individual/sole proprietor or
single-member LLC
C Corporation S Corporation Partnership Trust/estate
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)
a
Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check
LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is
another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
Other (see instructions)
a
4 Exemptions (codes apply only to
certain entities, not individuals; see
instructions on page 3):
Exempt payee code (if any)
Exemption from FATCA reporting
code (if any)
(Applies to accounts maintained outside the U.S.)
5 Address (number, street, and apt. or suite no.) See instructions.
6 City, state, and ZIP code
Requester’s name and address (optional)
7 List account number(s) here (optional)
Part I Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later.
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and
Number To Give the Requester for guidelines on whose number to enter.
Social security number
––
or
Employer identification number
–
Part II Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me)
; and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the
IRS has notified me that I am
no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
Sign
Here
Signature of
U.S. person
a
Date
a
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/FormW9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return with the IRS must obtain your correct taxpayer
identification number (TIN) which may be your social security number
(SSN), individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following.
• Form 1099-INT (interest earned or paid)
• Form 1099-DIV (dividends, including those from stocks or mutual
funds)
• Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
• Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
• Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TIN.
If you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
Cat. No. 10231X
Form W-9 (Rev. 11-2017)
Town of Brookhaven
Long Island
Edward P. Romaine, Supervisor
Department of Finance • Tamara Branson, Commissioner of Finance
One Independence Hill • Farmingville • NY 11738 • Phone (631) 451-6680 • Fax (631) 451-6692
www.brookhaven.org
February 14, 2019
Dear Valued Vendors;
The Town of Brookhaven would like to invite you to participate in our new and
convenient electronic payment option called Electronic Funds Transfer (EFT) by
utilizing the U.S. Treasury Department Automated Clearing House (ACH)
payment system, established by the United States Congress, Debt Collection
Improvement Act of 1996; Public Law 104-134.
An EFT enrollment form is attached. Please complete the form and attach a
copy of a void check mail to:
Town of Brookhaven
Finance Department/Accounts Payable
c/o Loretta O’Connor, Senior Accountant
One Independence Hill
Farmingville, New York 11738
(631) 451-6694
Upon receipt of the application, the Town Finance Department will update your
Vendor record with the EFT enrollment information to include (1) email address,
(2) bank account number and (3) bank routing number. Once updated, the
Finance Department will test the payment process prior to activating your new
payment option.
Your business will continue to invoice the Town of Brookhaven in accordance
with your established policy and procedure. Once the payment option test is
successful and your next invoice is approved and processed for payment the
following activity will occur:
1. The Town will email you an electronic remittance via Portable
Document Format (PDF) advice in lieu of printing a paper check and
mailing it to you. The PDF advice is similar to the printed check advice
currently available, it includes statement type information such as
invoice numbers, invoice date and amount of the invoices paid.
Town of Brookhaven
Long Island
Edward P. Romaine, Supervisor
Department of Finance • Tamara Branson, Commissioner of Finance
One Independence Hill • Farmingville • NY 11738 • Phone (631) 451-6680 • Fax (631) 451-6692
www.brookhaven.org
2. During a normal payment cycle the PDF payment advice will arrive on
a Thursday.
3. The Town Finance Department will process the EFT payment
instructions to our bank on Friday, the next business day.
4. The payment funds will be available for your use, in your designated
bank account on Monday, the next business day.
5. There are no fees imposed by the Town of Brookhaven or participating
banks.
Benefits to your company include:
- Timely processing of invoices, no limit on dollar amount or number of
invoices processed;
- Payment funds available immediately upon deposit/transmittal…no waiting
period.
- Eliminating check processing costs and collection costs associated with
lost or misplaced checks;
- No fees imposed by the Town of Brookhaven or participating banks;
- Reduced exposure to check fraud;
- Receipt of electronic remittance data for more efficient reconciliation;
- Going green, paperless, electronic payments are more secure, save
money and also help conserve the environment by eliminating printing and
mailing paper checks.
Please contact Loretta O’Connor at (631) 451-6694 or email her at
loconnor@brookhavenny.gov if you have any questions about this process. We
appreciate your business and look forward to providing your company with this
more efficient payment option.
The Town of Brookhaven is enthusiastic about these means of making payments
and look forward to working with your company to make this a successful
program.
Attached: EFT Enrollment Form
Town of Brooaven
Long Isld

EFT/ACH Enroment Form
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Mailing Address
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□
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
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


Signae __________________________



B
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
80
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HW 04 Complete Snow Packet PDF (Town of Brookhaven)

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Completed 16 July 2020

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