Fillable SUPPLIER ACH PAYMENT AUTHORIZATION FORM (Pierce County)

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SUPPLIER ACH PAYMENT AUTHORIZATION FORM (Pierce County)

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File type: PDF

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Finance Department
GARY ROBINSON
Director
950 Fawcett Avenue, Suite 100
Tacoma, Washington 98402
(253) 798-7285 FAX (253) 798-6699
PLEASE ALLOW 3 – 4 WEEKS FOR PROCESSING
SUPPLIER ACH PAYMENT AUTHORIZATION FORM
New Request Account Change Cancel
SUPPLIER INFORMATION
1
NAME
ADDRESS
CITY, STATE, and ZIP+4 CODE
ACCOUNTS RECEIVABLE CONTACT NAME/TITLE
ACCOUNTS RECEIVABLE CONTACT PHONE
BUSINESS EMAIL ADDRESS (for Remittance Advice)
EMPLOYER ID NO (EIN)
1a
MOST RECENT INVOICE # PAID BY PIERCE COUNTY (Existing
suppliers only)
DATE OF MOST RECENT INVOICE PAID BY PIERCE COUNTY
(Existing suppliers only)
PREVIOUS BANKING INFORMATION (ONLY REQUIRED FOR ACCOUNT CHANGE OR CANCELLATION)
2
DEPOSITORY INSTITUTION NAME
TRANSIT ROUTING NUMBER (ABA #)
ACCOUNT NUMBER
NEW BANKING INFORMATION
3
DEPOSITORY INSTITUTION NAME
TRANSIT ROUTING NUMBER (ABA)
ACCOUNT NUMBER
ACCOUNT TYPE CHECKING SAVINGS
IMPORTANT NOTE: The person signing the Authorization must be a designated officer and a person other than the
contact listed above.
AUTHORIZATION
4
I hereby authorize and request Pierce County to initiate credit entries for payee payments to the account designated in Section 3 of this
form. I agree to abide by the National Automated Clearing House Association (NACHA) rules pertaining to these entries.
SIGNATURE
DATE
PRINT NAME
TITLE
5
EMAIL (preferred):
pcacctspayable@piercecountywa.gov
MAIL:
Pierce County Finance Department
Attn: Accounts Payable
950 Fawcett Avenue,
Suite 100
Tacoma, WA 98402
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SUPPLIER ACH PAYMENT AUTHORIZATION FORM (Pierce County)

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Completed 25 April 2021

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