Enclousure D - ACH Authorization Form.pdf

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Attached to
Condensing and Air Handler Unit
Solicitation number
IO450418
Issued by

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This document is an ACH Authorization Form for vendors to provide their banking information to Brookhaven National Laboratory/Brookhaven Science Associates (BNL/BSA) for direct deposit of payments under a federal contract.

The form requests the vendor's company name, tax ID number, financial institution information including routing/transit/ABA number and checking account number, and an authorized representative's contact details. The vendor authorizes BNL/BSA to initiate ACH credit entries to the specified account, which can only be revoked by notifying the originator per NACHA rules. This form is required to facilitate electronic payments under the related federal contract opportunity.

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Other files

File Type Posted
Enclosure A - Draft PO 450418.PDF PDF
Enclousure E - W9 Form (Domestic Vendors).pdf PDF
Enclousure C - Quatation Pricing Sheet.pdf PDF
RFQ IO450418.pdf PDF
Enclousure B - Reps and Certs.pdf PDF
Enclousure F - W-8 Form (Foreign Vendors).pdf PDF

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Managed by Brookhaven Science Associates, LLC under contract with the

U.S. Department of Energy

Vendor ACH Authorization Form

VENDOR INFORMATION

Vendor/Company Name or DBA:

Vendor Number (if Applicable):

Tax ID Number (TIN):

DEPOSITORY INFORMATION

Financial Institution:

Routing/Transit/ABA Number:

Checking Account Number:

AUTHORIZATION

I (we) hereby authorize Brookhaven National Laboratory/Brookhaven Science Associates to make payments by initiating ACH (Automated Clearing House) credit entries or correcting entries to the account indicated above and associated with the financial institution named above. This authorization will remain in effect until BNL/BSA receives written notification to terminate or modify the same. It is my (our) understanding that credit authorizations may be revoked only by notification of the originator as described by NACHA (National Automated Clearing House Association) law.

Authorized Representative:

Email:

Phone:

Signature: Date:

VendorCompany Name or DBA:
Vendor Number if Applicable:
Tax ID Number TIN:
Financial Institution:
RoutingTransitABA Number:
Checking Account Number:
Authorized Representative:
Email:
Phone:
Date:

File details come from the government source that posted it. Updated .