Enclosure D. Vendor 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 that vendors must complete to authorize BNL/BSA to process payments via ACH (Automated Clearing House) credit entries or correcting entries. The Vendor Information section requires the vendor/company name or DBA, vendor number if applicable, and Tax ID Number (TIN). The Depository Information section collects banking details including the financial institution name, routing/transit/ABA number, and checking account number. Under the Authorization section, vendors authorize BNL/BSA to make ACH payments to the designated account, with the authorization remaining in effect until written termination or modification is received by BNL/BSA. The form requires signature from an authorized representative along with their email, phone number, and date of execution. Authorization revocation is governed by NACHA (National Automated Clearing House Association) law and can only be revoked by notification to the originator.