B.1 Enclosure 5 Vendor ACH Authorization Form.pdf

This is a Vendor ACH Authorization Form used by Brookhaven National Laboratory, managed by Brookhaven Science Associates, LLC under contract with the U.S. Department of Energy.

The form is a template that enables vendors to authorize Brookhaven National Laboratory to make payments via ACH (Automated Clearing House) credit entries or correcting entries to the vendor's designated bank account. The form requires vendors to provide vendor identification information including company name or DBA, vendor number if applicable, and Tax ID Number. Under the Depository Information section, vendors must supply their financial institution name, routing/transit/ABA number, and checking account number. The Authorization section contains a statement authorizing BNL/BSA to initiate ACH payments and specifies that the authorization remains in effect until written notification is received to terminate or modify it. Per NACHA (National Automated Clearing House Association) law, credit authorizations may only be revoked by notification of the originator. The form requires signature, date, and contact information from an authorized representative including name, email, and phone number.