Supplier Direct Deposit (ACH) Authorization/Update Form 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 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:

Notary Seal

Date of System Master Data Review: _____________________________

Revised 05-2025