3-Vendor Direct Deposit Authorization Form Updated 2020.pdf

221 KB Posted

Attached to
RFQuote 25-13 Holiday Decorations at Designated HCC Campuses
Solicitation number
RFQuote 25-13
Issued by
Harris County, Texas

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This document is a Vendor Direct Deposit Authorization Form from Houston Community College (HCC). The form is designed for vendors to set up, change, or cancel electronic payment arrangements with the college. It provides a structured process for vendors to authorize direct deposit of payments, with sections for payee identification, financial institution details, and transaction type selection.

The form requires vendors to provide key information including their Social Security Number or Federal Employer Identification Number, business contact details, and banking information. Vendors must complete the form using blue or black ink and can choose from several transaction types such as new setup, changing financial institutions, adding email notifications, or cancelling existing arrangements. The form includes an authorization statement where the vendor agrees to comply with National Automated Clearing House Association Rules and Regulations. Completed forms should be emailed to treasury.operations@hccs.edu, and vendors can contact HCC Treasury Operations at (713) 718-5078 for additional assistance.

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18. Email address used to send payment information

19. Address City State Zip Code

VENDOR DIRECT DEPOSIT AUTHORIZATION FORM

PAYEE IDENTIFICATION

S E

C T

IO

N

1. Social Security Number or

Federal Employer’s Identification (FEI)

2. Business phone number

3. Name 4. Street Address

5. City 6. State, Zip Code

AUTHORIZATION FOR SETUP, CHANGES OR CANCELLATION

S E

C T

IO

N

7. I authorize Houston Community College (HCC) to deposit my payments to my financial institution electronically. I understand that the Houston Community College will reverse any payments made to my account in error.

I consent and agree to be subject to and comply with the National Automated Clearing House Association Rules and Regulations pertaining to Originators and Receivers. I, the undersigned, represent and warrant that I am authorized to execute this document on behalf of the payee.

8. Authorized signature 9. Printed name 10. Title 11. Date

FINANCIAL INSTITUTION

S E

C T

IO

N

12. Financial institution name 13. City 14. State

15. Routing transit number 16. Customer account number 17.

Checking Savings

Representative Signature (Optional) Phone number Date

EMAIL ADDRESS

REMITTANCE ADDRESS AS LISTED ON YOUR INVOICE

CANCELLATION

S E

C

20. Reason Date

For HCC Official Use Only:

Vendor # Location # Address #

Entered by: Date Entered: / /

For additional information or assistance, please contact HCC Treasury Operations:

Phone: (713) 718-5078 Fax: (713) 718-8081

Email: treasury.operations@hccs.edu

New Setup (Sections 2, 3, 4, 5, 6) Change financial institution (Sections 2, 3, 4, 5, 6)

Add Email Notification

Cancellation

(Sections 2, 3, 4, 5, 6) Change account number (Sections 2, 3, 4, 5, 6)

(Sections 2, 3, 7) Change email notification (Sections 2, 3, 4, 5, 6)

S E

C

S

E C

S E

C T

IO

N

INSTRUCTIONS

● Use only BLUE or BLACK ink.

● Alterations must be initialed.

TRANACTION TYPE

● Complete all sections as required

● Complete all appropriate box (es).

● E-mail completed form to: treasury.operations@hccs.edu

1 Social Security Number or Federal Employers Identification FEI:
2 Business phone number:
3 Name:
4 Street Address:
5 City:
6 State Zip Code:
9 Printed name:
10 Title:
11 Date:
12 Financial institution name:
13 City:
14 State:
15 Routing transit number:
16 Customer account number:
Representative Signature Optional Phone number:
Date:
18 Email address used to send payment information:
19 Address City State Zip Code:
20 Reason Date:
Vendor:
Location:
Entered by:
Date Entered:
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Check Box1: Off
Check Box2: Off
Check Box3: Off
Check Box4: Off
Check Box5: Off
Check Box6: Off
Check Box7: Off
Check Box8: Off
Text9:
Text10:
Text11:
Text12:
Text13:

File details come from the government source that posted it. Updated .