ACH_Authorization_Agreement_form_04012022.pdf
PDF 3 MB Posted
- Attached to
- Merchant Credit Card Services
- Solicitation number
- 15200-25-002
- Issued by
- San Mateo County, San Bernardino City, California
About this file
ACH Authorization Agreement Form
This is an ACH Authorization Agreement form used by the County of San Mateo to establish direct deposit payment arrangements with vendors and entities providing goods or services to the county. The form authorizes San Mateo County to initiate credit transactions and, if necessary, debit transactions and adjustments to a vendor's designated bank account. The agreement requires vendors to provide complete entity information, tax identification numbers, primary contact details, and a valid email address for payment notifications. Vendors must select their ACH request type—whether initiating direct deposit authorization, changing bank information, or terminating an existing authorization—and designate an authorized officer to sign the agreement. The authorization remains in full force and effect until either the County or the Vendor submits a written termination request. Vendors are responsible for notifying the County of any modifications to their bank account information that could impact payment processing.
The form requires vendors to submit supporting documentation including a bank statement with transactions redacted, an original voided check, and a completed and signed IRS Form W-9. All required documentation must be mailed or hand-delivered to the specific County department with which the vendor conducts business. The form explicitly states that all fields are mandatory and must be printed clearly, with authorization provided through the wet signature of an authorized officer. The County reserves the right to cancel the Authorization Agreement and terminate direct deposits with or without cause, with written notification to be sent to the vendor's business email and/or mailing address. The form ensures compliance with United States law regarding ACH transaction origination.
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Text version
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.pdf |
| ACH_Authorization_Agreement__111418.pdf |
| ACH form Instructions rev 061919 |
ACH form Instructions rev 021919.pdf
| EntityVendor Name: |
| Tax Identification Number: |
| EntityVendor Address: |
| EntityVendor Primary Phone Number: |
| EntityVendor EMail Address for Payment Notification: |
| I as an authorized officer for the Entity the Vendor hereby authorize San Mateo County the County to initiate direct: Off |
| Financial Institution Name: |
| Transit ABA Number: |
| Financial Institution Address: |
| Bank Account Number: |
| City: |
| State: |
| ZIP: |
| Print Name: |
| Title: |
| Date: |
| undefined: |
| undefined_2: |
| Phone Number: |
| Email: |
| Processed By: |
| Date_2: |
| undefined_3: |
| Radio Button5: Off |
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