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.

The form is a template that authorizes BNL/BSA to process payments to vendors through Automated Clearing House (ACH) credit entries or correcting entries. Vendors must provide their company name or DBA, vendor number (if applicable), and Tax ID Number. The depository information section requires the financial institution name, routing/transit/ABA number, and checking account number. The authorization section contains standard language indicating that the authorization remains in effect until BNL/BSA receives written notification to terminate or modify it, and that credit authorizations may only be revoked through notification to the originator as governed by NACHA (National Automated Clearing House Association) law. An authorized representative must complete the form by providing their name, email, phone number, signature, and date. This is a supporting document template rather than a solicitation or contract document with specific procurement requirements.