Attachment_4_-_Electronic_Funds_Transfer_Authorization.pdf

Electronic Funds Transfer Authorization

(via Automated Clearing House) Revised 2/8/2018

SECTION 1. Enrollment Type

Please select the box that indicates the enrollment action.

New Change Certification Cancel

If this is a change or a request to add to an existing vendor, please indicate the vendor number:

SECTION 2. Remittance E-Mail Notification

Please provide one or more Accounts Receivable e-mail addresses where ACH remittance information should be sent:

E-mail 1:

E-mail 2:

SECTION 3. Account Information

Name of Individual/Business:

Name of Financial Institution:

Branch Number or Name: Branch Phone:

Financial Institution Address (Number and Street):

City: State: Zip Code:

Checking Savings

Depositor Account Number:

Type of Account:

Nine-Digit Routing Number:

Re-enter Routing Number: Re-enter Account Number:

SECTION 4. Authorization

1. Select the appropriate action:

Authorize direct deposit of payments due the entity named in Section 3 Cancel direct deposit for the entity named in Section 3

2. Provide certification information:

I certify that the entire amounts authorized to be received by this account are not subject to be transferred to a foreign bank account. I acknowledge that if this box is not selected, the Judicial Council of California (JCC) will issue all payments by check only.

If I transfer money from this account to an offshore bank, I will cancel this authorization and notify the JCC. This authorization remains in full force and effect until the JCC receives written notification from the entity of its termination in such manner as to afford the JCC and financial institution a reasonable opportunity to act on it, or until the JCC terminates the agreement. This authorization and any future notifications must be sent to one of the contacts listed in Section 5:

Authorized Signature of Entity Named in Section 3:

Signature

Provide the last 4-digits the taxpayer identification number associated with this vendor:

Provide an e-mail address below where we can contact you to verify your request:

Date:

Phone:

SECTION 5. General Instructions

1. To enroll for direct deposit of payments from the Superior Courts of California or change, certify, or cancel your existing direct deposit, complete sections 1, 2, 3 and 4 of this form (all information must be legible). Please include an e-mail address in section 4, as we will contact you to verify your request.

2. To obtain routing number or account number information, contact your financial institution.

3. Your direct deposit will continue to be deposited into your designated account at your financial institution until the JCC is notified that you wish to re-designate your account and/or your financial institution. To re-designate, complete and submit a new form with the new information. Do not close your old account until your first payment is deposited into your newly designated account and/or financial institution.

4. Submit this form to your court representative who will forward it to the Judicial Council of California.

ATTACHMENT 4