INSTRUCTIONS
General Instructions: Please indicate at the top of the EFT Payment Authorization Form whether the
authorization is new, a change or a cancellation request. Additionally, indicate your preference for Wire
or automated clearing house (ACH) transfer type. Wire funds are received the same day they are
processed; however, a $10 transaction fee will be deducted from your payment. ACH funds are not
available until the following business day. There is no charge to the vendor.
Complete all remaining sections of the form and forward (along with a voided blank check) to:
New Jersey School Development Authority
Attention: Vendor Services
P.O. Box 991
Trenton, NJ 08625-0991
Section I: Vendor Information
Section II: Financial Institution Information
Section III: Vendor Authorization
http://www.njsda.gov/Reports.net/web_public/paymentlog_SDA.aspx
Vendors may confirm the receipt of a payment by viewing the SDA's website at:
Revised: 3/11/14
NJSDA G/A Form 1293
EFT Payment Authorization Form
Attn: Vendor Services
Page 1 of 2
Provide W-9 with completed EFT payment authorization form. (required)
Enter the business address (not a P.O. Box).
.
.
Enter the remittance address as a second payment option.
.
Provide the name and telephone number of a contact person.
.
Provide e-mail address and fax number for the contact person.
.
.
Provide your bank name and the bank's State.
Enter your bank 9 digit routing ABA / Transit number and your bank account number.
Enter the name(s) on your bank account.
.
Indicate the type of bank account (check one box only).
.
Obtain bank representative's signature certifying the bank information associated with the vendor
name in Section I of this form is true and accurate. This signature is REQUIRED ONLY IF a
voided blank check is not attached to the EFT Payment Authorization Form.
Print bank representative's name and title.
.
An authorized representative of the vendor must sign and date the EFT Payment Authorization
Form and include his/her title and telephone number.
.
.
.
EFT Payment Authorization Form
Request Type
(check one)
:
Section I: Vendor Information
Section II: Financial Institution Information
Account Type
(check one)
:
If checking account, attach
a VOIDED blank check
Financial Institution Certification:
(required ONLY if a voided check is not attached)
I certify that the preceding Bank ABA / Transit Number, Account Name, Account Number and Account Type are true and
accurate for the vendor named in Section I of this EFT Payment Authorization Form.
Bank Representative's Signature:
Section III: Vendor Authorization
I certify that, as an authorized representative for the above named vendor, the information above is true and correct and
hereby authorize the New Jersey Schools Development Authority to electronically deposit Wire / ACH transactions to the
designated bank account. This authorization shall remain in full force until the New Jersey Schools Development Authority
receives written notification requesting a change or cancellation.
NEW
CHANGE
CANCELLATION
Vendor Name:
Business Address:
City, State, and Zip:
FEIN / Social Security Number:
Contact Person:
ABA / Transit Number:
Account Name:
Bank Name:
SAVINGS
LOCKBOXCHECKING
Phone Number:
Date:
Title (Print):
Name (Print):
Payment Type
WIRE ($10 fee)
ACH (No Charge)
(check one):
Remittance Address:
City, State, and Zip:
Bank State:
Account Number:
Bank Representative's Name (Print):
Fax Number:
E-mail:
Attn: Vendor Services
NJSDA G/A Form 1293
Revised: 3/11/14
Page 2 of 2
Phone Number:
Authorized Signature:
Date:
Title:
Print Form
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