4-Direct Deposit Authorization Form 5.15.2025.pdf.pdf

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VICTOR D. CRIST

CLERK OF CIRCUIT COURT & COMPTROLLER

HILLSBOROUGH COUNTY, FL

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

e. Mail the original form to our office.

f. 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

EXCELLENCE IN SERVICE!

MINNINIMIMMINIL

(813) 276-8100 1 HILLSCLERK.COM

P.O. BOX 1110, TAMPA, FL 33601.1120

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.

• 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 Revised Payee Name (Last, First, Middle Initial or Entity Name) Payee Tax ID

Payee Address (Street)

City State

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

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

September 2024

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

Zip Code

Banking Information

Mailing Instructions

Sep 2024

HILLSBOROUGH COUNTY FLORIDA BOARD OF COUNTY COMMISSIONERS

TERMS AND CONDITIONS FOR DIRECT DEPOSIT PARTICIPATION

Please Read This Carefully

The origination of Direct Deposits through Automated Clearing House (ACH) transactions must comply with the provisions of state and federal laws and regulations. The Tax ID and bank account information is required to establish ACH payments. This information will remain confidential to the extent provided by law. Failure to provide the requested information will prevent establishment of Direct Deposit. Payees who are not active vendors in the County's financial system must also submit a Hillsborough County Substitute W‐9.

Proper completion of the Direct Deposit Authorization Form (DDA) authorizes the Hillsborough County Clerk of the Circuit Court, as Chief Financial Officer and Comptroller for the Hillsborough County Board of County Commissioners (County), to initiate credit and, if necessary, debit entries and adjustments for any credit entries made in error to the designated account, at the Financial Institution named, and to credit or debit the same from such account. This authorization will remain in effect until cancelled in writing, refer to Changes or Cancellations section below.

Information Found On Checks Most of the information required to complete the Direct Deposit Authorization Form is printed on the payee's checks or deposit tickets. The payee name and address on the check, deposit ticket, bank account title and supplier account must match the information on the DDA. Please make sure addresses are current.

Prenotification A prenotification ACH credit (prenote) to the account designated on the DDA will be made prior to making direct deposit payments based on this authorization. The prenote is a test deposit transaction to your financial institution for the purpose of verifying the transfer of funds to the payee bank account as designated on the DDA. When the prenote is processed, an e‐mail will be sent to the payee. The payee must respond to the prenote email upon verification of the prenote in the payee's account. Payments will not be made by Direct Deposit until the prenote has been accurately confirmed by the payee. If the prenote fails due to an error on the DDA, the payee will be notified. Depending on the reason, the payee may be required to submit a new DDA to begin the process again.

Changes or Cancellations This authorization remains in effect until cancelled by the payee in writing to the Hillsborough County Clerk County Finance Department (Clerk) at the address provided on the bottom of the DDA. Changes in banking information are treated as cancellations and the payment method will revert to check. A new DDA must be submitted and fully processed to change the payment method to Direct Deposit again.

Sufficient time must be allowed to process changes and cancellations. Urgent matters, such as fraudulent activity on your bank account, should be immediately addressed by phone. Upon cancellation by the payee, the payee should also notify the receiving financial institution that the authorization has been cancelled. The County and the Clerk expressly reserve the right to discontinue Direct Deposit at any time.

The Financial Institution, at their discretion, may also discontinue direct deposit services. Should this occur, the payee must immediately notify the Clerk. If the payee's or County's financial institution reports any event of fraud related to the payee, payee's bank account, or to the payee's DDA, the DDA shall be cancelled immediately without prior notice. Further, supplier payments by check may be placed on hold until the event is resolved to the Clerk's satisfaction. This action is intended for the protection of the County and the supplier/payee.

Violations, False Statements or Fraud Violation of these Terms and Conditions may cause termination of participation in Direct Deposit. Neither the Clerk nor the County will be responsible for any loss which may arise solely by reason of error, mistake or fraud regarding information provided on a Direct Deposit Payment Authorization Form. Anyone who misrepresents or falsifies essential information to receive payment is subject to applicable Federal and State laws and regulations.