ACH_Authorization_Agreement_form_04012022.pdf

County of San Mateo

Entity/Vendor Name

Authorization Agreement for ACH PAYMENTS (Vendor Direct Deposit)

Note: All fields on this form are required

Tax Identification Number

Entity/Vendor Address *

Entity/Vendor Primary Phone Number Entity/Vendor E-mail Address for Payment Notification **

* If address is PO Box, contact County department for additional instructions.

** Must include a valid e-mail address as all payment notifications will be sent via e-mail ONLY

I, as an authorized officer for the Entity (the Vendor), hereby authorize San Mateo County (the County), to initiate direct deposit (credit) transactions and, if necessary, debit transactions and adjustments for any credit transactions made in error to the same bank account indicated below.

Financial Institution Name Transit / ABA Number

Financial Institution Address Bank Account Number

City State ZIP

This Authorization Agreement will remain in full force and effect until the County or the Vendor has acted on a written request for termination. Such termination must be made in a timely manner so as to afford the County a reasonable opportunity to act on it. The Vendor is responsible for notifying the County on any modifications made to the existing bank account that could impact the County from making ACH payment transactions directly deposited to the above bank account number.

Select the ACH Request Type:

Initiate direct deposit authorization

Change bank information

Terminate/cancel direct deposit authorization

As an authorized officer for the Vendor, I understand that the County reserves the right to cancel the Authorization Agreement and terminate such direct deposits with or without cause, followed by a written notification to my business email and/or the Vendor’s mailing address. I understand that the origination of an ACH transaction (debit or credit) to or from the Vendor’s account must comply with the laws of the United States of America.

Signature of Authorized Officer

Print Name

Date Title

Phone number of the Authorized Officer

Email address of the Authorized Officer

**** REQUIRED DOCUMENTS ****

1. Required Banking Information. (Both A & B are required)

A. A Bank Statement (Transactions Redacted/Crossed Out) B. An original voided check

2. Completed and signed IRS FORM W-9

PEID Date

FOR COUNTY PURPOSES ONLY

Processed

INSTRUCTIONS FOR COMPLETING THE AUTHORIZATION AGREEMENT FOR AUTOMATIC PAYMENTS

Important - Please print all information on form clearly

Once you have completed the required Authorization Agreement, IRS W-9 forms and banking verifications, they must be mailed or hand delivered to the County department you provide goods or services to.

Enter complete Entity or Vendor Name. For sole proprietorship, this may be the name or DBA name as listed on the Federal Income Tax return, Schedule C, for the business.

Enter Tax Identification Number or Social Security Number, as applicable.

Enter complete Entity/Vendor Address. (PO Box requires additional information)

Enter Entity/Vendor primary phone number.

Enter Entity/Vendor e-mail address where ACH payment notification will be sent.

The ACH payment notification contains all detailed information normally appearing on the stub of a paper check.

Enter the name of the financial institution associated with the Entity/Vendor’s ACH payments.

Enter the Transit or American Banking Association (ABA) Number (located on the Business or Personal check – see pictorials below).

Enter the bank account number associated with your direct deposit (located on the Business or Personal check – see pictorials below).

Enter complete address of Financial Institution.

Endorse using a wet signature of Authorized Officer for the Vendor.

Print name of Authorized Officer for the Vendor.

Enter Title of Authorized Officer for the Vendor.

Enter phone number and email address of Authorized Officer for the Vendor.

Entity/Vendor Name

Tax Identification Number

Entity/Vendor Address

Entity/Vendor Primary Phone Number

Entity/Vendor E-mail Address for Payment Notification

Financial Institution Name

Transit/ABA Number

Bank Account Number

Financial Institution Address, City, State, Zip

Signature of Authorized Officer for the Vendor

Print Name

Title

Phone Number and Email Address of Authorized Officer for the Vendor

Account Number Account Number

Sample Transit / ABA Number

Sample Transit / ABA Number

ACH form Instructions rev 021919.pdf