3-Direct Deposit Authorization Form.pdf

Cindy Stuart

CLERK OF COURT & COMPTROLLER

HILLSBOROUGH COUNTY

Hillsborough County Suppliers:

The Hillsborough County Board of County Commissioners offers suppliers the option of receiving payments by direct deposit. With direct deposit, payments are made electronically by ACH directly to the supplier's designated bank account.

Direct deposit is...

• Quick - No waiting for the mail. Payments are automatically credited to your account.

• Convenient - No worry about getting to the bank to make a deposit.

• Economical - No cost to receive Direct Deposit and you have access to your funds sooner.

• Secure - No paper checks to handle (avoids risk of misplacement, loss or theft).

• Reliable - ACH payments are tested prior to activation of payment on actual invoices.

Enrollment in the County's Direct Deposit process is simple.

a. Read the attached Terms and Conditions.

b. Provide all information on the Direct Deposit Payment Authorization Form.

c. Complete and sign the Payee Certification.

d. Take the form to your bank for Financial Institution Certification (your bank must do this part).

e. Attach a voided check, deposit ticket or letter from your financial institution.

1. Mail the original form to our office.

g. Confirm the test deposit transaction in your bank account.

The Direct Deposit Authorization Form and Terms and Conditions are attached. If you have questions about the process or how to complete the form, just call (813)276-2029 ext. 5684.

Sincerely, Ajay Gajjar

Finance Director

Enclosures

Equity. Transparency. Independence.

t s (813) 276-8100 f0) HILLSCLERK.COM

P.O. Box 1110, Tampa, FL 33601-1110

March 2023

Hillsborough County Florida Board of County Commissioners

Direct Deposit Authorization Form Directions

• Read the Terms and Conditions for Direct Deposit Participation (attached) and all instructions on the form carefully.

• Complete the form in ink. It must be clear and legible. Incomplete forms will not be processed.

• Do not mark through corrections. Do not use correction fluid. If an error is made, please start a new form.

• Payee must complete the Payee Information and Payee Certification sections.

• Financial Institution must complete, certify and sign, the Financial Institution Certification (take the form to your bank).

• Do not submit faxes or copies of this form, only the original completed and signed form will be accepted.

• Payments will be made using the Corporate Trade Exchange (CTX) format.

Payee Information New Revision Payee Name (Last, First, Middle Initial or Entity Name) Payee Tax ID

Payee Address (Street, City, State, Zip Code)

Payee Telephone (incl. area code & ext.) Payee Email Address (to use for payment notifications)

Financial Institution Name

Financial Institution Address (Street, City, State, Zip Code)

Routing Transit Number Payee Account Number Account Type

Checking Savings Payee Account Title

Payee Certification By signing this form, I authorize payments to be sent to the financial institution named above to be deposited to the designated account. I have read and accept the Terms and Conditions for Direct Deposit Participation.

Payee or Payee Agent Signature Date

Payee or Payee Agent Name (Print) Payee or Payee Agent Title

Financial Institution Certification I confirm identity of the above named payee, account number and title. As an authorized representative of the above named Financial Institution, I certify that the Financial Institution agrees to receive and deposit payment as designated by the payee above in accordance with NACHA operating rules and regulations.

Financial Institution Representative Signature Date

Financial Institution Representative Name/Title (Print) Financial Institution Representative Telephone/Email

Attach a VOIDED unused check here for checking accounts.

Mark VOID in amount or signature area only.

Attach an unused deposit slip here for savings accounts.

Alternatively, attach an original letter from your financial institution on their letterhead, signed by their authorized representative, which confirms at least the account name, routing number and account number.

Mail properly completed and signed (original) form with voided check, deposit slip or bank letter attached to:

Clerk of Circuit Court County Finance Department PO Box 1110 Tampa FL 33601-1110 County Finance Department Telephone (813) 276-2029 ext. 5684

0_ Direct Deposit Letter and Application Jan 2019