ACH_Authorization_Form.pdf
PDF 290 KB Posted
- Solicitation number
- PB-25-0825
- Issued by
- Hamilton County, Indiana
About this file
This is an ACH/EFT Authorization Agreement Form issued by the Hamilton County Auditor's Office in Noblesville, Indiana, establishing procedures for electronic payment processing to vendors and suppliers. The form requires suppliers to provide their company information, including name, address, Tax ID/EIN, and contact details, along with banking information for their financial institution. Suppliers must designate either a checking or savings account and provide their routing and account numbers. The authorization remains in effect until written termination notice is provided to the Hamilton County Auditor. Suppliers must attach either a voided check or bank verification letter to validate the account information, and any changes to banking details or financial institutions require submission of a new authorization agreement with updated documentation, including a bank verification letter for new accounts and confirmation of authorized signatory approval.
The form emphasizes that suppliers are responsible for maintaining accurate email addresses for electronic funds transfer notifications and must promptly notify the Hamilton County Auditor's Office of any account changes to avoid payment delays. The document includes an internal control verification section for auditor use to confirm supplier existence and verify bank account information through independent sources. This authorization agreement is a standard requirement for suppliers participating in Hamilton County contracts, including the Multi-Bridge Rehabilitation Project involving the rehabilitation of Bridge 140 at Hazel Dell Parkway over Cool Creek and Bridge 164 at Cumberland Road over Mud Creek in Hamilton County, Indiana.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Hamilton_140_&_164:_Final_Contract_Documents.pdf | ||
| Hamilton_County_Bridge_164_Final_Plans.pdf | ||
| Hamilton_County_Bridge_140_Final_Plans.pdf | ||
| W-9.pdf | ||
| Bid_Bond.pdf |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
ACH / EFT AUTHORIZATION AGREEMENT FORM
Hamilton County Auditor
33 N 9th Street
Noblesville, IN 46060
Supplier Information
Name: ___________________________
Address: ___________________________
City, State, Zip:______________________
Tax ID / EIN: ___________________________
Please provide a current W-9
Contact Person Phone # ___________________________
Contact E-mail_______________________________
Financial Institution’s Information
Bank Name: ___________________________
Bank Address: ___________________________
City, State, ZIP: ___________________________
Account Type: ☐ Checking ☐ Savings
Routing Number: ___________________________
Account Number: ___________________________
E-mail address where notices of EFT deposits to the bank account specified above:
A voided check or bank verification letter will need to be attached.
Any change to the account or to a new financial institution will require a new
Authorization Agreement. Failure to timely notify the Hamilton County Auditor of an account change will delay payment.
New Financial Institution’s Information
Bank Name: ___________________________
Bank Address: ___________________________
City, State, ZIP: ___________________________
Account Type: ☐ Checking ☐ Savings
Routing Number: ___________________________
Account Number: ___________________________
A Bank verification letter for the new account must be attached.
Documentation confirming authorized signatory approval
E-mail address where notices of EFT deposits to the bank account specified above:
Authorization & Certification
I certify that I am authorized to provide this banking information on behalf of the above-named entity. I authorize Hamilton County to initiate ACH/EFT credit payments to the above account.
This authorization remains in effect until written notice of termination is provided.
BY SIGNING THIS FORM
Hamilton County will initiate credits (deposits) in various amounts, by electronic transfer of funds through automated clearing house (ACH) processes, to the listed checking or savings account designated in the financial institutions named above.
You acknowledge that it will cause disruption to the notification process if the email address provided for electronic funds transfer notification are frequently changed or changed without promptly providing an updated email address to the Auditor.
You are responsible for contacting the Hamilton County Auditor’s Office if you are not receiving electronic notices of EFT deposits.
Internal Control Verification (For Auditor Use Only)
• Supplier existence verified: ☐ Yes ☐ No
• Bank account verified via independent source: ☐ Yes ☐ No
• Verified By: ___________________________
• Date: ___________________________
File details come from the government source that posted it. Updated .