20-Supplier Direct Deposit Authorization Form 05-2025.docx
DOCX document 112 KB Posted
- Attached to
- Biology and Honors Biology Textbook Adoption
- Solicitation number
- RFP 27004TLH
- Issued by
- Clark County, Fish Springs CDP, Nevada
About this file
Supplier Direct Deposit Authorization Form Summary
This is a Supplier Direct Deposit (ACH) Authorization/Update Form issued by the Clark County School District (CCSD) in Nevada, revised as of May 2025. The form is designed to establish or modify direct deposit banking information for suppliers and vendors conducting business with CCSD. The document requests the supplier's main or corporate business information, federal tax identification number or SSN, and complete financial institution details including routing number and account number. Suppliers must provide either a voided check or bank letter as supporting documentation and have the authorization form notarized before submission to the CCSD Accounts Payable department located at 4190 McLeod Drive, Las Vegas, Nevada 89121.
The form establishes authorization for CCSD to initiate direct deposit payments into the supplier's designated financial institution account and remains valid until the district receives a new signed authorization form. The supplier bears sole responsibility for the accuracy of the account number and routing information provided. The completed form must be mailed, faxed to (702) 799-5482, or submitted via telephone contact at (702) 799-5360 to the Accounts Payable department. The form includes internal sections for Accounts Payable review and verification, with spaces for reviewer initials, verification date/time, and administrator approval before entry into the system master data.
View the file
Other files
Show all 20
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .