VENDOR AUTHORIZATION AGREEMENT FOR ACH PAYMENT
Directions
•
Type or print the information requested in Sections 1 and 2. Then sign, date, and return the form with your Vendor
package.
•
Any account changes must be reported to DCA within ten (10) days prior to actual change. A payee must keep DCA
informed of any address changes in order to receive important information about benefits and to remain qualified for
payments. Please refer to the application instructions, if applicable.
Section 1 - Entity to Receive Direct Deposit
Type of Transaction: Add Change Delete
Name of Company OR Individual County Telephone
Street Address City State Zip
Contact Person Email
9-digit Federal Tax ID
Section 2 - Financial Institution Authorized to Conduct Transaction
Financial Institution County Telephone
Street Address City State Zip
Type of Account
Checking Savings
9-digit Transit Routing/ABA Number
Account Number at Above Institution
Whereby we authorize DCA to initiate credit entries to our account in the financial institution our account identified above
and also debit entries, if necessary, for any credit entries that are determined to be in error. We additionally authorize the
financial institution to credit or debit the same to our account.
This authority is to remain in effect until revoked by us in writing to DCA
.
Signature Title
Type or Print Name Date
For DCA use only Date Received Date Entered Initials
