Exhibit C - ACHAuthorizatonForm_EFT form.pdf

rev 06/2022

VENDOR DIRECT DEPOSIT / EFT

ACH AUTHORIZATION FORM

SECTION I (AGENCY USE) - PAYOR, STATE INFORMATION

STATE AGENCY VENDOR CODE

MAILING ADDRESS ADDRESS ID

CITY, STATE ZIP VERIFIED BY**

AGENCY CONTACT/EMAIL VERIFICATION METHOD:

VENDOR/VERIFICATION CONTACT PHONE EMAIL

** State employee who performed independent verification per the EFT Setup/Change guidance (step 8) on the CORE site

SECTION II – PAYEE, VENDOR INFORMATION

PAYEE NAME PHONE

DOING BUSINESS AS (DBA, OPTIONAL)

MAILING ADDRESS

CITY, STATE, ZIP

EMAIL (FOR REMITTANCE ADVICE)

SECTION III – DEPOSITORY FINANCIAL INSTITUTION AND ACCOUNT INFORMATION

PLEASE INCLUDE A VOIDED CHECK (NOT A TEMPORARY CHECK OR DEPOSIT SLIP) AND/OR

SIGNED BANK LETTER THAT INCLUDES ALL INFORMATION REQUESTED IN THIS SECTION

BANK NAME BRANCH ADDRESS

ROUTING NUMBER ACCOUNT NUMBER

ACCOUNT TYPE CHECKING SAVINGS FOR FURTHER CREDIT (OPTIONAL)

PAYEE TAXPAYER ID NUMBER (SSN OR EIN, NO DASHES)

SHOULD ALL STATE OF COLORADO PAYMENTS TO THIS TAXPAYER ID USE THIS BANK ACCOUNT? YES NO

IF NO, PLEASE EXPLAIN

SECTION IV – AUTHORIZATION FOR ACH / DIRECT DEPOSIT SETUP, CHANGE, OR CANCEL

SETUP CHANGE CANCEL FOR CHANGES ONLY, PLEASE PROVIDE EXISTING ROUTING & ACCOUNT NUMBER

ROUTING NUMBER EXISTING ACCOUNT NUMBER

I certify that I have the authority to execute this authorization. I hereby authorize the State of Colorado to initiate ACH credit entries (deposits) and if necessary to reverse any incorrect ACH payments made in error to the above bank account. In the event a reversal cannot be implemented, I understand the State will utilize any other lawful means to recover the deposited funds to which the payee was not entitled. This authorization is to remain in full force until the state has received written notification of cancellation in such time as to afford a reasonable opportunity to act on it.

PRINTED NAME TITLE

SIGNATURE DATE

EXHIBIT C

DOING BUSINESS AS (DBA, OPTIONAL)

MAILING ADDRESS

CITY, STATE, ZIP

SECTION III – DEPOSITORY FINANCIAL INSTITUTION AND ACCOUNT INFORMATIONPLEASE INCLUDE A VOIDED CHECK (NOT A TEMPORARY CHECK OR DEPOSIT SLIP) AND/OR

SIGNED BANK LETTER THAT INCLUDES ALL INFORMATION REQUESTED IN THIS SECTION

PAYEE TAXPAYER ID NUMBER (SSN OR EIN, NO DASHES)

SHOULD ALL STATE OF COLORADO PAYMENTS TO THIS TAXPAYER ID USE THIS BANK ACCOUNT? YES NO

IF NO, PLEASE EXPLAIN

I certify that I have the authority to execute this authorization. I hereby authorize the State of Colorado to initiate ACH credit entries (deposits) and if necessary to reverse any incorrect ACH payments made in error to the above bank account. In the event a reversal cannot be implemented, I understand the State will utilize any other lawful means to recover the deposited funds to which the payee was not entitled. This authorization is to remain in full force until the state has received written notification of cancellation in such time as to afford a reasonable opportunity to act on it.