ACH_Authorization_Form.pdf
PDF 290 KB Posted
- Solicitation number
- HC-26-02 / HC-0916
- Issued by
- Hamilton County, Indiana
About this file
ACH Authorization Form Summary
This is an ACH Authorization Form supporting the Contract Resurface 26-02 project for asphalt milling and resurfacing of roads in Jackson and Noblesville Townships, Indiana. The form establishes the mechanism for electronic funds transfer (ACH) payments from the contracting government entity to the selected contractor. The document facilitates payment processing for the road resurfacing work, which encompasses 3.28 miles of road milling and asphalt resurfacing across seven primary road segments, including 211th Street, Mill Creek Road, Point Lane, Cherry Tree Road, Bays Drive, Susan Court, and Angela Court. The project scope also includes supplementary work such as 8-inch deep patching, transverse crack sealing, pavement fabric installation, pipe replacements, curb and casting replacements, and inlet cleaning within the Cherry Tree Farms subdivision.
The ACH Authorization Form serves as the payment authorization document that enables the contractor to receive compensation through automated clearing house transfers rather than traditional payment methods. By executing this form, the contracting jurisdiction establishes banking and account information for direct deposit of contract payments, streamlining the financial administration of the project. The form is a standard administrative requirement that must be completed and authorized by the contractor prior to contract execution and the commencement of work performance.
View the file
Other files
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 .