21-Supplier Direct Deposit Authorization Form 05-2025.docx
DOCX document 112 KB Posted
- Attached to
- Chemistry and Honors Chemistry Textbook Adoption
- Solicitation number
- RFP 27003LMK
- Issued by
- Clark County, Nevada
About this file
This is a Supplier Direct Deposit (ACH) Authorization/Update Form used by the Clark County School District (CCSD) in Nevada for managing vendor payment methods. The form allows suppliers and vendors to establish or modify direct deposit banking information for receiving payments from the district. Suppliers must complete the form with their business information, federal tax identification or social security number, and primary contact details. The financial institution information section requires documentation of the supplier's banking credentials, including the routing number, account number, and account type (checking or savings), along with a voided check or bank letter as verification. The authorization must be notarized and signed by an authorized supplier representative, and the supplier acknowledges sole responsibility for the accuracy of all account information provided.
The form remains in effect until the CCSD receives a new signed authorization form and has sufficient time to process it. Suppliers may cancel the authorization at any time by submitting a new form. The completed form must be mailed to the CCSD Accounts Payable department at 4190 McLeod Drive, Las Vegas, Nevada 89121, and can be submitted by telephone or fax for inquiries. The CCSD Accounts Payable department is responsible for reviewing and verifying the authorization information, with internal sections for reviewer initials, verification documentation, and administrator approval. This form is essential for any vendor seeking to receive payments through direct deposit from the district.
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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 .