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) to establish electronic payment processing for vendors.

The form is a template designed to collect vendor banking information and authorize ACH (Automated Clearing House) payments. The Vendor Information section requires the vendor/company name or DBA, vendor number if applicable, and Tax ID Number (TIN). The Depository Information section captures the financial institution name, routing/transit/ABA number, and checking account number. The Authorization section contains language authorizing Brookhaven National Laboratory/Brookhaven Science Associates to initiate ACH credit entries and correcting entries to the designated account. The authorization remains in effect until written notification is received to terminate or modify it, and may only be revoked per NACHA (National Automated Clearing House Association) law procedures. The form requires signature from an authorized representative along with their email, phone number, and date of authorization.