B1 Enclosure D ACH Authorization Form.pdf

This is a Vendor ACH Authorization Form used by Brookhaven National Laboratory/Brookhaven Science Associates, managed under contract with the U.S. Department of Energy, to establish electronic payment processing for vendors.

The form requires vendors to provide identification information including company name or DBA, vendor number (if applicable), and Tax ID Number. Vendors must also supply depository information consisting of the financial institution name, routing/transit/ABA number, and checking account number. By signing the authorization, vendors authorize Brookhaven National Laboratory/Brookhaven Science Associates to initiate ACH (Automated Clearing House) credit entries or correcting entries to the specified account. The authorization remains in effect until BNL/BSA receives written notification to terminate or modify it. The form must be signed by an authorized representative who provides their name, email address, and phone number, along with the date of authorization. Per NACHA (National Automated Clearing House Association) law, credit authorizations may be revoked only through notification to the originator.