18-Supplier Direct Deposit Authorization Form 05-2025.docx
DOCX document 112 KB Posted
- Attached to
- Physics and Honors Physics Textbook Adoption
- Solicitation number
- RFP 27001BJN
- Issued by
- Clark County, Nevada
About this file
This is a Supplier Direct Deposit Authorization Form used by the Clark County School District in Nevada to establish or update automatic clearing house (ACH) payment arrangements with vendors and suppliers. The form serves as the official document through which suppliers authorize the district to initiate direct deposit payments to their designated financial institution accounts. The form requires submission of supporting documentation, including a voided check or bank letter, and must be completed with the supplier's business information, federal tax identification or social security number, and detailed financial institution data including routing and account numbers. Completed forms are submitted to the Accounts Payable Department located at 4190 McLeod Drive, Las Vegas, Nevada 89121, via mail, fax, or telephone contact.
The authorization must be signed in the presence of a notary public and remains in effect until the Clark County School District receives a newly executed form and has reasonable opportunity to implement the changes. Suppliers acknowledge sole responsibility for the accuracy of all account and routing information provided. The form includes sections for Accounts Payable internal use, including reviewer initials, verification documentation, and administrator approval, with designated fields for system master data review and supplier maintenance dates. This standard administrative form is applicable to all vendors contracting with the Clark County School District, including those bidding on instructional materials such as physics and honors physics textbooks for high school curriculum adoption.
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Text version
Supplier Direct Deposit (ACH) Authorization/Update FormRevised 05-2025
Mail completed form with required attachment to:
Accounts Payable, 4190 McLeod Drive Las Vegas, NV 89121 Telephone: (702) 799-5360 Fax: (702) 799-5482
Supplier Main or Corporate Business Name & Address (as it appears on W-9) Information
Description of Request:
New
| Change |
| Federal Tax ID, SSN or Employee ID Number: |
Name:
Address:
City:
State:
Zip Code:
CCSD Vendor Number:
Telephone:
Fax
Email Address for Notification of Payment:
Supplier Financial Institution Information (A copy of a Voided Check or Bank Letter is required to be attached)
Financial Institution Name:
Telephone:
Address:
City:
State:
Zip Code:
Financial Institution Routing Number:
Account Number:
Account Type:
Checking
Savings
Supplier Authorization- Signed in the presence of a Notary Public
Supplier hereby authorize the Clark County School District to initiate direct deposit on my entire payment into my account. I further authorize the financial institution indicated above to credit the same to such account. This authority is to remain in full force and effect until the Clark County School District has received a new signed Direct Deposit Authorization Form and has a reasonable opportunity to act. I acknowledge that I am solely responsible for the accuracy of the account number and the financial institution ABA number that I have provided.
Supplier hereby cancels this authorization.
In witness, Whereof, I have hereunto set my hands this day of
| , |
| 20 |
Printed Name and Title of Authorized Supplier Representative:
Signature :
Date:
STATE OF
| , |
| COUNTY OF |
This document was acknowledged
Notary Seal before me on
(date)
By
Person appearing before notary
Signature of notarial officer
Accounts Payable Internal Use Only Accounts Payable Reviewer Initials:
Verification date and time:
Telephone:
Name and Title of Contact:
Administrator Approval Initials:
Date submitted of Supplier Maintenance:
Date of System Master Data Review: _____________________________ image1.png image10.png
File details come from the government source that posted it. Updated .