Type of authorization (select one only):

☐ NEW: Enter all banking information requested below and submit this form. (Complete lines 1-12 and 16-22) Note: Student refunds, Lottery payments, DORS payments, Renters tax credits, and Restitution payments are NOT eligible for ACH.

☐ CHANGE: Complete this form by entering changes to the financial institution, account number, or type of account; and submit the completed form. Do not close your old bank account until electronic payments are received in your new account. (Complete all lines)

☐ CANCELLATION (Revocation): You may cancel (revoke) your prior Authorization by checking this box and completing and submitting this form. (Complete lines 1-7, 13-15 and 17-22)

Please complete all sections of this Enrollment Form and attach either a voided check OR a letter signed by your bank representative, confirming account name, account number, and ABA routing number for ACH payments. Starter checks or counter checks are NOT acceptable. Online credit cards are NOT eligible for ACH transfer.

Send completed form and documentation to: State of Maryland, Comptroller of Maryland, ACH Registration, General Accounting Division, Room 205, P.O. Box 746, Annapolis, Maryland 21404-0746 or fax the form to 410-974-2309. If you have any questions, contact the General Accounting Division at 410-260-7813 or toll free at 888-784-0144.

Please type or print legibly.

PAYEE INFORMATION

The number below is:

☐ Social Security No.(SSN) ☐ Federal Employer No.(FEIN)

1. Payee Name 2. SSN or FEIN

3. Mailing Address 4. City, State, ZIP Code

5. E-mail address

6. Contact Name and Title 7. Daytime Telephone Number

NEW – Complete 8-12 OLD BANK ACCOUNT INFORMATION – Complete 13-15

8. Financial Institution Name 13. Financial Institution Name

9. ABA/Routing Number 14. ABA/Routing Number

10. Account Number 15. Account Number for Deposit of Electronic Funds Transfer

11. Account Type (Select one only) ☐Checking ☐Savings

12. Financial Institution Telephone Number

16. Level of Detail on Bank Statement Requested (select one only):

☐ Standard format – CCD+ (DEFAULT) ☐ Detailed format - CTX* (multiple detail lines) ☐ Detailed format - EDI* (full detail) Example: “State of Maryland” “State of Maryland and Invoice Information”

*Note: You must contact your bank to receive these detailed formats. There may be a charge to you by your bank for detailed formats.

I hereby certify that I am authorized to make the representations contained in this paragraph. I authorize the Comptroller and the Treasurer of Maryland to register the payee for automated clearing house (ACH) using the information contained in this registration form. I agree to receive all vendor payments from the State of Maryland by electronic funds transfer according to the terms of the ACH program. I agree to return to the State of Maryland any ACH payment incorrectly disbursed by the State of Maryland. I agree to hold harmless the State of Maryland and its agencies and departments for any delays or errors caused by inaccurate or outdated registration information or by the financial institution listed above.

17. Print or Type Name of Payee or Payee’s Authorized Signatory 18. Title of Authorized Signatory

19. Signature of Payee or Payee’s Authorized Signatory 20. Date

21. Signature of Secondary Signatory(s) – if applicable 22. Date

ADMINISTRATIVE USE ONLY

GAD Input By: ____________________________________ STO Input By: _______________________________________ GAD Reviewed By: ________________________________ STO Reviewed By: ___________________________________ COT/GAD X-10 (Rev 9/20)

STATE OF MARYLAND

ACH/DIRECT DEPOSIT

AUTHORIZATION FOR VENDOR PAYMENTS

“State of Maryland and Invoice Information”

MWHEATLEY

Highlight

Purpose:

To provide information to the State of Maryland for ACH/Direct Deposit.

Who will use the form?

Vendors that are required to have payments made via ACH/Direct Deposit or other vendors requesting payments via ACH/Direct Deposit.

Routing and General Instructions:

Complete and send the form and documentation to Vendor Services in the General Accounting Division. Please retain a copy of the form for your records.

Submit to:

ACH Registration, General Accounting Division Room 205, P.O. Box 746 Annapolis, Maryland 21404-0746

(or) Fax to 410-974-2309

Processing:

Allow 14 days from the date of your request for the Comptroller’s/Treasurer’s office to process your request.

Payments will be processed according to payment terms.

Questions: Email to GADCSC@marylandtaxes.gov, call 410-260-7813 or toll free at 888-784-0144.

COT/GAD X-10 (Rev 9/20)

STATE OF MARYLAND

ACH/DIRECT DEPOSIT

INSTRUCTION SHEET

mailto:GADCSC@marylandtaxes.gov