ACH_Authorization_Form.pdf
PDF 290 KB Posted
- Solicitation number
- PR-26-0836
- 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, in connection with the Hamilton County 146th Street and Hazel Dell Parkway Intersection Improvement Project. The form serves as the mechanism by which suppliers and contractors engaged on county projects authorize electronic funds transfer payments directly to designated bank accounts. The document requires suppliers to provide complete banking information, including routing numbers, account numbers, and account type, along with either a voided check or bank verification letter as supporting documentation. Any changes to financial institution information or account details require submission of a new authorization agreement and updated bank verification documentation to prevent payment delays. The form includes provisions for notifying the county of authorized signatory approval and designates an email address for receiving electronic funds transfer deposit notifications.
The authorization grants Hamilton County the ability to initiate ACH/EFT credit deposits in various amounts to the supplier's specified checking or savings account, with the agreement remaining effective until written termination notice is provided. Suppliers are responsible for maintaining accurate and current email addresses for deposit notifications and must promptly inform the Hamilton County Auditor's Office of any changes to avoid disruption to the notification process. The form includes internal control verification checkboxes for auditor use to confirm supplier existence and independent verification of bank account information. This standardized authorization form is a prerequisite administrative requirement for vendors seeking payment through electronic means on Hamilton County construction and improvement projects.
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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 .