Electronic_Funds_Transfer_08_11-SRR.pdf

Vendor Authorization for Electronic Funds Transfer (EFT) Payments

Please check (x) the appropriate box:

_____ New authorization _____ Change existing authorization

Please attach a copy of a voided check from your checking account (No deposit slips, please)

VENDOR INFORMATION

Vendor Name (as identified on P.O.): ______________________________________________

Vendor Address (as identified on P.O.): ______________________________________________

Vendor Phone Number: ______________________________________________

Vendor Fax Number: ______________________________________________

Vendor Accounts Receivable Contact: ______________________________________________

Accounts Receivable E-mail Address: ______________________________________________

BANKING INFORMATION

Depository (Bank) Name: ______________________________________________

Depository (Bank) Address: ______________________________________________

Bank Contact: ______________________________________________

Bank Contact Phone Number: ______________________________________________

Deposit Account Title: ______________________________________________

Deposit Account Number: ______________________________________________

Bank Routing Transit Number (RTN) or American Bankers Association (ABA) Number (9 digits): ______________________________________________

Type of Account: Checking ______________ Savings _______________

I hereby authorize Savannah River Remediation to initiate credit entries to the above bank account for the payment of funds/invoices due to the vendor indicated. In the event of an overpayment, the vendor agrees to issue a refund to SRR on their company check. Additionally, I understand that in the event the above account should be closed or I determine that payment should not be deposited into the above account, it will be my responsibility to notify SRR Accounts Payable in a timely manner to have the deposits discontinued and to provide new account information.

Co-Authorizing Signature Date Accounts Receivable Signature Date

Please mail, email or SRR, LLC - Accounting EMAIL: SRRAccountspayable@srs.gov fax this form to: P. O. Box 369 FAX: 803-952-9386

New Ellenton, SC 29809-0369 PHONE: 803-952-9677

08/08/11 (Rev. 3)