B1 Enclosure D_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 designed to authorize electronic payment processing through the Automated Clearing House (ACH) system.

The form collects vendor identification information including company name or DBA, vendor number (if applicable), and Tax ID Number. It requires depository information specifying the financial institution, routing/transit/ABA number, and checking account number where payments should be deposited. The authorization section grants Brookhaven National Laboratory/Brookhaven Science Associates permission to initiate ACH credit entries or correcting entries to the designated account. The authorization remains in effect until written notification is received to terminate or modify it, with revocation permitted only in accordance with NACHA (National Automated Clearing House Association) law. The form requires signature by an authorized representative along with their email, phone number, and date of execution.