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 in Noblesville, Indiana, designed to establish electronic payment procedures for suppliers and contractors conducting business with Hamilton County. The form requires suppliers to provide comprehensive banking information including financial institution details, account numbers, routing numbers, and account type designations (checking or savings). Suppliers must submit a voided check or bank verification letter as supporting documentation, and any changes to banking information or financial institutions require submission of a new authorization agreement and bank verification letter to prevent payment delays. The form includes provisions for updating financial institution information and requires suppliers to maintain current email addresses for electronic funds transfer deposit notifications, with suppliers bearing responsibility for contacting the Auditor's Office if notices are not received.
The authorization grants Hamilton County the ability to initiate ACH/EFT credit payments in various amounts to the designated account, with authorization remaining in effect until written termination notice is provided. The form includes an internal control verification section for the Auditor's use to confirm supplier existence and verify bank account information through independent sources. Suppliers must certify that they are authorized representatives of their entity and acknowledge their responsibility for account maintenance and notification updates. This document is a standard administrative requirement for contractors bidding on the Hamilton County Multi-Bridge Rehabilitation Project involving Bridges 140 and 164, and must be completed prior to contract award and payment processing.
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 | ||
| ACH_Authorization_Form.pdf | ||
| Bid_Bond.pdf |
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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 .