B1 Enclosure D 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) to establish electronic payment processing for vendors.

The form is a template designed to authorize BNL/BSA to make payments to vendors through ACH (Automated Clearing House) credit entries or correcting entries. Vendors must complete three sections: Vendor Information (requesting vendor/company name or DBA, vendor number if applicable, and Tax ID Number); Depository Information (requiring the financial institution name, routing/transit/ABA number, and checking account number); and Authorization (containing the authorization statement and requiring signature, date, authorized representative name, email, and phone number). The authorization remains in effect until BNL/BSA receives written notification to terminate or modify it, with revocation governed by NACHA (National Automated Clearing House Association) law.