California State
University
ADMINISTRATIVE
SERVICES
CHANNEL
ISLANDS
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D D
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Procurement and Logistical Services
AUTOMATED CLEARING HOUSE (ACH) ENROLLMENT AND AUTHORIZATION FORM
Cancel ACH Direct Deposit
For an ACH payment, CSU Channel Islands requires either 1) the individual's name and social security number (SSN) OR
2) the company's name and federal employer identification number (FEIN), as they appear on your income tax return.
Please complete this form and submit to CSU Channel Islands. An email will be sent to the address on file confirming
the change.
PLEASE PRINT LEGIBLY
First Name, Last Name or Company Name:
SSN or FEIN:
Address or PO Box:
Phone number:
Bank Name: Bank Address:
Bank Routing Number:
Bank Account Number: Select one: Checking Savings
One of the Following Items Must be Provided:
Most recent PO # and date: Amount of last payment received:
Company quote # and date: Employee home address on file with HR:
I (we) hereby authorize CSU Channel Islands and the Financial Institution named above, to initiate credit entries to my (our) account
indicated above at the depository Financial Institution named above and to initiate, if necessary, debit entries and adjustments for
any credit entries in error. CSU Channel Islands reserves the right to reverse any duplicate or erroneous credit entries. I (we) certify
that the ACH payment is being made to a domestic financial institution and will not be transferred in its entirety to a foreign
institution as part of a back to back transaction.
If signed by a corporate officer, partner or fiduciary on behalf of a business, organization or corporate entity, I certify that I have the
authority to execute this authorization. This authorization is to remain in full force until CSU Channel Islands has received written
notification from an authorized account holder of its termination in such manner as to afford CSU Channel Islands and its financial
institution reasonable opportunity to act on the notice. It is my (our) responsibility to provide an updated ACH Enrollment Form to
CSU Channel Islands updating any changes to my (our) Financial Institution, routing number and account number(s).
If any action taken by me (us) results in no acceptance of a direct payment by the designated Financial Institution, I (we) understand
that CSU Channel Islands assumes no responsibility for processing a supplemental payment until the amount of the no accepted
deposit is returned to CSU Channel Islands by the Financial Institution.
Authorized Signature: Date:
Printed Name of Authorized Official: Title:
**PLEASE ATTACH A VOIDED CHECK OR OTHER FINANCIAL INSTITUTION DOCUMENTATION WITH CORRECT ACCOUNT AND
ROUNTING NUMBERS HERE TO CONFIRM ACCOUNT INFORMATION** (DEPOSIT SLIPS NOT ACCEPTED)
Submit completed form via email: purchasing@csuci.edu FAX: (805) 437-8436
For questions, please contact Karina Cruz at: (805) 437-8581
