B1 Enclosure D ACH Authorization Form.pdf

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

The form is a template designed to authorize BNL/BSA to make electronic payments to vendors via Automated Clearing House (ACH) credit entries or correcting entries. Vendors must complete the Vendor Information section, which requires the company name or DBA, vendor number (if applicable), and Tax ID Number (TIN). The Depository Information section requires the financial institution name, routing/transit/ABA number, and checking account number. By signing the Authorization section, the vendor authorizes BNL/BSA to initiate ACH payments to the designated account. The authorization remains in effect until BNL/BSA receives written notification to terminate or modify it. According to NACHA (National Automated Clearing House Association) law, credit authorizations may only be revoked by notification of the originator. The authorized representative must provide their name, email, phone number, signature, and date to complete the form.