ESBD_File_341671_Vendor-Onboard-Package.pdf

SIC Security Zone code

4. Name of payee (Individual or business to be paid)

5. Mailing address where you want to receive payments

6. (Optional)

7. (Optional)

8. (Optional)

9. City State ZIP code

10.

Se ct io n

Payee telephone number (Area code and number) type code ( 0, 1, 2 ) code

Payee Information (Please type or print)

2. Texas Identification Number (TIN) - Indicate the type of number you are providing to be used for your TIN Employer Identification Number (EIN) (9 digits)

Se ct io n

1 Social Security number (SSN) (9 digits)

Individual Taxpayer Identification Number (ITIN) (9 digits)

Comptroller's assigned number (FOR STATE AGENCY USE ONLY) (11 digits) Current Texas Identification Number (FOR STATE AGENCY USE ONLY) (11 digits)

3. Are you currently reporting any Texas tax to the Comptroller's office such as sales tax or franchise tax? YES NO

Enter the number indicated

If "YES," enter Texas Taxpayer Number

1. Is this a new account? YES Mail Code 000 NO Enter Mail Code Agency number Complete Sections 1 - 5 Complete Sections 1, 2 & 5

For Comptroller's use only

11. Ownership Codes - Check only one code by the appropriate ownership type that applies to you or your business.

L - Texas Limited Partnership:

If checked, enter the

Texas File Number

T - Texas Corporation:

If checked, enter the

Owner's name Texas File Number

SSN / ITIN (9 digits) A - Professional Association:

If checked, enter the

Se ct io n

3 Texas File Number

C - Professional Corporation:

If checked, enter the Texas File Number

I - Individual Recipient (not owning a business)

S - Sole Ownership (Individual owning a business): If checked, enter the owner's name and Social Security number (SSN)

P - Partnership: If checked, enter two partner's names and Social Security numbers (SSN). If a partner is a corporation, use the corporation's Employer Identification Number (EIN).

N - Other: If checked, explain.

O - Out-of-State CorporationName

G - Governmental EntitySSN / ITIN / EIN (9 digits)

U - State agency / University Name

F - Financial Institution SSN / ITIN / EIN (9 digits)

R - Foreign (out of U.S.A.)

Se ct io n

Se ct io n

Agency name Prepared by Phone (Area code and number)

12. Payment Assignment? YES NO Note: A copy of the assignment agreement between payees must be attached.

Assignee name

Assignee TIN Assignment date

13. Comments Authorized signature (Applicant or authorized agent) Date

14.

15.

AP-152

(Rev.8-17/17)

Application for Texas Identification Number

• See instructions on back

Who Must Submit This Application - This application must be submitted by every person (sole owner, individual recipient, partnership, corporation or other organization) who intends to bill agencies of the state government for goods, services provided, refunds, public assistance, etc. The Texas Identification Number (TIN) will be required on all maintenance submitted by state agencies. The use of this number on all billings will reduce the time required to process billings to the State of Texas.

Note: To expedite processing of this application, please return the completed application to the state agency with which you are conducting business. It is not necessary for the payee to sign or complete this form. The state agency representative may complete the form for the payee.

For Assistance - For assistance in completing this application, please call the Texas Comptroller's office at 1-800-531-5441, ext. 6-8138, or 512-936-8138.

Notice to State Agencies - When this form is used to set up additional mail codes, Sections 1, 2 and 5 must be completed. State agencies may refer to the Texas Identification Number System (TINS) Guide at https://fmx.cpa.state.tx.us/fmx/pubs/tins/tinsguide for additional information.

General Instructions -

• Do not use dashes when entering Social Security, Employer Identification, Individual Taxpayer Identification or Comptroller's assigned numbers.

• Disclosure of your Social Security number is required. This disclosure requirement has been adopted under the Federal Privacy Act of 1974

(5 U.S.C.A. sec. 552a(note)(West 1977), the Tax Reform Act of 1976 (42 U.S.C.A. sec. 405(c)(2)(C) (West 1992), TEX. GOV'T. CODE ANN. sec. 403.055 (Vernon 2005) and TEX. GOV'T. CODE ANN. sec. 403.056 (Vernon 2005). Your Social Security number will be used to help the Texas Comptroller of Public Accounts administer the state's tax laws and for other purposes.

See Op Tex. Att'y Gen. No. H-1255 (1978).

Specific Instructions - Section 1 - Texas Identification Number

EIN: For all ownership codes other than Individual Recipient listed in Section 3, enter a 9-digit Employer Identification Number (EIN) issued by the Internal Revenue Service.

SSN: For Individual Recipient or Sole Owner without an EIN, enter your 9-digit Social Security number (SSN) issued by the Social Security Administration.

ITIN: For Individual Recipient or Sole Owner without an EIN, enter your 9-digit Individual Taxpayer Identification Number (ITIN) issued by the IRS.

Comptroller Assigned Number – 11 digits: FOR STATE AGENCY USE ONLY. A Comptroller Assigned Number is an ID number that is given to a state agency that needs to pay either a foreign entity or a foreign individual who does not have an EIN, SSN or ITIN.

Current Texas Identification Number – 11 digits: FOR STATE AGENCY USE ONLY.

Are you currently reporting any Texas tax to the Comptroller's office such as sales tax or franchise tax? If "YES," enter Texas Taxpayer Number.

Section 2 - Payee Information Items 4 through 8 - Enter the complete name and mailing address where you want payments to be received. Names of individuals must be entered first name first. Each line cannot exceed 50 characters including spaces. If the name is more than 50 characters, continue the name in Item 5 and begin the address in Item 6.

Item 9 - Enter the city, state and ZIP code.

Item 10 - Enter payee telephone number.

SIC code, Security type code and Zone code: FOR STATE AGENCY USE ONLY.

Section 3 - Ownership Codes Item 11 - Check the box next to the appropriate ownership code and enter additional information as requested. Please check only one box in this section. The Secretary of State's office may be contacted at 512-463-5555 for information regarding Texas file numbers.

Section 4 - Payment Assignment Item 12 - Use when one payee is assigning payment to another payee. When setting up an assignment payment, fill out this section completely and include a copy of the assignment agreement between the assignee and the assignor.

Section 5 - Comments and Identification Item 13 - Enter any additional information that may be helpful in processing this application. Items 14 and 15 are for identification purposes. Always complete the identification section, including comments and authorized signature.

Under Ch. 559, Government Code, you are entitled to review, request and correct information we have on file about you, with limited exceptions in accordance with Ch. 552, Government Code. To request information for review or to request error correction, contact us at the address or phone numbers listed on this form.

Form AP-152 (Back)(Rev.8-17/17)

Fiscal Management Aust in, TX 78774-0100

G L E N N H E G A R T E X A S C O M P T R O L L E R O F P U B L I C A C C O U N T S

Application for Texas Identification Number

Direct Deposit Authorization

For Comptroller’s Use Only74-176

(Rev.4-14/18) S

E C

T

IO

N

Transaction Type

New setup (Sections 2, 3, 5 and 6) Change account type (Sections 2, 3, 4, 5 and 6)

Change financial institution (Sections 2, 3, 4, 5 and 6) Cancellation (Sections 2 and 6 - Sections 7 and 8 for state agency use)

Change account number (Sections 2, 3, 4, 5 and 6)

S E

C

Cancellation by Agency (for state agency use) Reason Date

S E

C

International Payments Verification (required)

Will these payments be forwarded to a financial institution outside the United States? ......................................................... YES NO

If "YES," also complete the ACH (Direct Deposit) Payment Destination Confirmation (Form 74-227).

Authorization for Setup, Changes or Cancellation (required)

S E

C T

IO

N

Authorized signature Printed name Date

I authorize the Texas Comptroller of Public Accounts to deposit my payments from the state of Texas to my financial institution electronically.

I understand that the Texas Comptroller of Public Accounts will reverse any payments made to my account in error.

I further understand that the Texas Comptroller of Public Accounts will comply at all times with the National Automated Clearing House Association's rules. (For further information on these rules, please contact your financial institution.)

This form may be used by vendors, individual recipients or state employees to receive payments from the state of Texas by direct deposit or to change/cancel existing direct deposit information.

Signature Date

Phone number Agency number

Agency name

Comments

Authorized Signature (for state agency use)

S E

C T

IO

N

TEXAS COMPTROLLER OF PUBLIC ACCOUNTS

Fiscal Management - Direct Deposit Program

P.O. Box 13528

Austin, TX 78711-3528

FAX: 512-475-5424 Phone: 512-936-8138

Please return your completed form to:

ext.

Financial institution name City State

Routing transit number (9 digits) Customer account number (maximum 17 characters) Type of account

Checking Savings

Financial representative name (optional) Title (optional)

Financial representative signature (optional) Phone number (optional) Date (optional)

New Account Information (Setups and Changes) (Completion by financial institution is recommended.)

S E

C T

IO

N ext.

Payee name Phone number

Mailing address City State ZIP code

Payee Identification

S E

C T

IO

N

Texas Identification Number (TIN)

Employer Identification Number (EIN)

Social Security Number (SSN)

Individual Taxpayer Identification Number (ITIN) State employee

Vendor or other recipient ext.

Mail code (If not known, leave blank.)

Payee type

Routing transit number (9 digits) Customer account number (maximum 17 characters) Type of account

Checking Savings

Existing Account Information (Changes Only)

S E

C

Instructions for Direct Deposit Authorization

You have certain rights under Chapters 552 and 559, Government Code, to review, request and correct information we have on file about you. To request information for review or to request error correction, use the contact information on this form.

Form 74-176 (Back)(Rev.4-14/18)

Section 1: Transaction Type

Section 2: Payee Identification

Section 6: Authorization for Setup, Changes or Cancellation

Section 5: International Payments Verification

Section 7: Cancellation by Agency

Section 8: Authorized Signature

For state agency use only.

Provide reason for cancellation request.

For State Agency Use

Must be completed in its entirety, and no alterations to the authorization language will be accepted.

Check "YES" or "NO" to indicate if direct deposit payments to the account information designated in

Section 3 of this form will be forwarded to a financial institution outside the United States. If "YES," also complete the ACH (Direct Deposit) Payment Destination Confirmation (Form 74-227).

Section 3: New Account Information (Needed for setups and changes)

Completion by financial institution is recommended.

Important: Your direct deposit account information may be different from the account information printed on your checks. It is recommended that you contact your financial institution to confirm your direct deposit account information.

Prenote Test:

A prenote test will be sent to your financial institution for the account information provided. The prenote test is for a period of six banking days, and it is sent to your financial institution to verify your account information. If no further action is required by your financial institution, your direct deposit instructions will become effective when the six banking day prenote time frame has expired.

Select payee type, provide the Texas Identification Number (TIN), Employer Identification Number (EIN)

Social Security Number (SSN)* or Individual Taxpayer Identification Number (ITIN) and enter payee contact information.

*Federal Privacy Act Statement

Disclosure of your Social Security number is required and authorized under law, for the purpose of tax administration and identifica-tion of any individual affected by applicable law, 42 U.S.C. sec. 405(c)(2)(C)(i); Texas Govt. Code Sections 403.011, 403.056, and

403.078. Release of information on this form in response to a public information request will be governed by the Public Information Act, Chapter 552, Government Code, and applicable federal law.

Select the appropriate transaction type(s).

Section 4: Existing Account Information (Needed for changes to existing account information)

When requesting a change to your existing direct deposit account information, you must complete Section

4 with the existing account information for verification purposes. This measure will help the paying state agency verify accuracy of the requested change.

Any change to banking information begins a prenote test period. See explanation in Section 3, above.

Accounts Payable/Direct Deposit Program 1100 West 45th Street Austin, TX 78756-3413

Phone: 512-454-8631