D-2- FRM-0870 Supplier Payment Information Changes.pdf

Please Select One or More Options Below Add Supplier Payment Address Remove Supplier Payment Address Add Bank Information Add Accountant Contact Info Remove Old Accountant Contact Info Other- Indicate here:

Federal Tax Identification Number Payment Method- If Changing Payment Method, Select New Preferred Method Only Check Preferred EFT Preferred *NOTE: See EFT enrollment requirements below

Supplier Name

Alternative DBA Name (If Applicable)

Payment Remittance Address New/ Current Address

New/ Current City , State

Old City, State (If Applicable) Postal Code

Vendor's Accounts Receivable Contact Information

Required Documents Attached?

Bank Routing Number Account

Number

Internal Official Use Only

Supplier Number Date of Change Changes Made By

Approver Signature

E-mail:

Signature:

Be aware that follow-up by company may occur to ensure validity and accuracy banking information.

Bank Name City, State, Zip Code:

Name on Account Authorized Signer User Telephone Number

I hereby authorize Mission Support and Test Services,LLC (MSTS), to initiate credit entries to the account at the bank listed below for all payments. This agreement will remain in effect until I notify MSTS of the desire to cancel or change this service or until MSTS notifies me that this service has been terminated. I understand I must allow reasonable time for my instructions to be executed. I authorize and request the bank listed below to accept any credit entries by MSTS to such account and to credit the same to such account. MSTS will not debit or deduct funds directly from my bank account for over-payments and/or refund requests, but MSTS will seek permission to debit my bank account for any adjustments or corrections to resolve duplicate payments (where “duplicate” is defined as MSTS sending multiple identical payments in error) or erroneous payments due to a bank account setup error. MSTS will attempt to recover the duplicate or erroneous payment via a debit to my account to the extent permitted by state law and with prior contact to me. If an electronic debit is unsuccessful, MSTS will notify me in writing to reach an alternative arrangement for reimbursement. MSTS strictly adheres to the National Automated Clearing House Association (NACHA) guidelines.

Old Address No Longer In Use (If Applicable)

Submit completed form and required documents to:

SupplierMaint@nv.doe.gov Section 3: Authorized Account Signer Information

By signing below, I hereby agree that I have read and agree to the terms and conditions stated below

*MUST ATTACH VOIDED CHECK or CERTIFIED BANK LETTER and W-9 OR ELSE EFT ENROLLMENT WILL BE DENIED

Section 1: Action Required

Company Form FRM-0870 Supplier Payment Information Changes

WHEN COMPLETED, THIS FORM MAY CONTAIN SENSITIVE PII AND INFORMATION SUBJECT TO THE PRIVACY ACT 05/14/18 Rev. 07

Both- Explain:

Vendor's Old/Removed Contact Information (If Applicable) Name (Print) Individual (Group Email If Available) Telephone Number

Section 2: Electronic Payment Enrollment

YES NO

Change Payment Method

Remove Old Bank Information

Effective Date of New Information End Date of Old Information

Postal Code