ACH form.pdf
PDF 164 KB Posted
- Attached to
- Check Stock Paper
- Solicitation number
- RFB-OC113-24
- Issued by
- Orange County, New York
About this file
The document is an Electronic Funds Transfer (EFT) and Automated Clearing House (ACH) Authorization Form from the Orange County Department of Finance, located in Goshen, NY. The form allows vendors doing business with Orange County to choose between receiving payments via traditional check or electronic ACH transfer. Vendors interested in receiving payments through ACH must complete the form, providing their banking details, contact information, and either a voided check or a bank letter with a bank representative's signature.
The form requires vendors to select whether they want to set up a new ACH payment method, change an existing method, or opt out of ACH payments. To process the request, vendors must provide their bank routing/ABA number, account number (checking or savings), and at least one valid email address for invoice details. The form notes that it may take one to two payment cycles before the first ACH payment is received. The document is signed by Kerry Gallagher, Commissioner of Finance, and includes the signature of County Executive Steven M. Neuhaus.
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Text version
Department of Finance Orange County Department of Finance
255 Main St.
Goshen, NY 10924
Phone: 845-360-6666
AUTHORIZATION FORM
ELECTRONIC FUNDS TRANSFER (EFT) & AUTOMATED CLEARING HOUSE (ACH)
Steven M. Neuhaus County Executive
Authorization is (select one):
New Change
Opt out of ACH Payment
Dear Vendor:
We are now able to offer you a choice between ACH or check for payment when doing business with Orange County. If you would like to continue receiving a check you do not need to do anything and can disregard this letter. If you would like to start receiving payments by ACH, please provide the information below. Once your letter is completed, please return it to our office.
Supplier/Vendor Name: Contact Name:
Address Line 1: Telephone: ( ) –
Address Line 2: Fax: ( ) –
Address Line 3: Last 4 digits of Tax ID/SSN:
City: State: Zip Code:
I hereby authorize ORANGE COUNTY to initiate credit entries, and to initiate, if necessary, debit entries and adjustments for any credit entries in error to my (select one): Checking Account Savings Account indicated below and the depository bank named below to credit and/or debit the same to my account.
Bank Name:
Routing/ABA Number:
Account Number:
One of the following is required in order for this request to be processed (check one):
Voided Check
Bank Letter or Specification Sheet
(no starter checks) (the signature of your local bank representative MUST be included)
A detail of the invoice(s) being paid will be emailed. Please provide at least one (1) valid email address:
Email #1:
Email #2:
Authorized Signature: Date:
It may take one to two payment cycles before you will receive your first payment by ACH. If you have any questions, please contact our office.
Sincerely, Kerry Gallagher
Commissioner of Finance
File details come from the government source that posted it. Updated .