EXHIBIT F - EFT Authorization Form.pdf
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- Attached to
- In-Car Digital Evidence Recording System
- Solicitation number
- RFP RBAA 2019000099 4
- Issued by
- Broomfield County, Denver City, Colorado
About this file
This is an EFT Direct Deposit Authorization Form used by the Colorado Department of Public Safety to establish, modify, or cancel electronic funds transfer (EFT) arrangements for vendor payments. The form serves as the official authorization document for setting up direct deposit accounts and includes sections for state department information, payee and vendor details, financial institution and account information, and authorization parameters. Vendors or payees must complete the form with their banking details, including routing number, account number, account type, and taxpayer identification information. The authorization remains in full force until the state receives written cancellation notice, allowing the state to process payments via electronic transfer to the designated bank account.
The form requires submission of supporting documentation in the form of a voided check or signed bank letter confirming all depository account information. Vendors must certify they have authority to execute the authorization and acknowledge that the state may reverse any incorrect EFT payments and utilize lawful means to recover funds to which the payee was not entitled. The form indicates whether all payments to a specific taxpayer ID should be directed to the designated bank account or whether alternative arrangements apply. This authorization document is standard administrative documentation necessary for vendors conducting business with the State of Colorado to receive contract payments through direct deposit rather than check.
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Text version
rev 08/2017
EFT DIRECT DEPOSIT
AUTHORIZATION FORM
SECTION I (DEPARTMENT USE) - PAYOR, STATE INFORMATION
STATE DEPARTMENT VCUST#
MAILING ADDRESS ADDRESS ID
CITY, STATE, ZIP VERIFIED BY
DEPARTMENT CONTACT
EMAIL PHONE
SECTION II – PAYEE, VENDOR INFORMATION
VENDOR NAME
D/B/A (DOING BUSINESS AS, OPTIONAL)
MAILING ADDRESS
CITY, STATE, ZIP
EMAIL (FOR REMITTANCE ADVICE) PHONE
SECTION III – DEPOSITORY FINANCIAL INSTITUTION AND ACCOUNT INFORMATION
INCLUDE A VOIDED CHECK (NOT A TEMPORARY CHECK OR DEPOSIT SLIP) 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 (SSN/EIN)
SHOULD ALL PAYMENTS TO THIS TAXPAYER ID USE THIS BANK ACCOUNT? YES NO
IF NO, PLEASE EXPLAIN
SECTION IV – AUTHORIZATION FOR DIRECT DEPOSIT SET UP, CHANGE, OR CANCEL
SET UP 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 herby authorize the State of Colorado to initiate, change, or cancel EFT credit entries (deposits) and if necessary to reverse any incorrect EFT payments made in error to the bank account indicated above. 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
X
X
Colorado Department of Public Safety
700 Kipling Street
Lakewood, CO 80215
| STATE DEPARTMENT: |
| VCUST: |
| MAILING ADDRESS: |
| ADDRESS ID: |
| CITY STATE ZIP: |
| VERIFIED BY: |
| DEPARTMENT CONTACT: |
| EMAIL: |
| PHONE: |
| VENDOR NAME: |
| DBA DOING BUSINESS AS OPTIONAL: |
| MAILING ADDRESS_2: |
| CITY STATE ZIP_2: |
| EMAIL FOR REMITTANCE ADVICE: |
| PHONE_2: |
| BANK NAME: |
| BRANCH ADDRESS: |
| ACCOUNT TYPE: Off |
| FOR FURTHER CREDIT OPTIONAL: |
| SHOULD ALL PAYMENTS TO THIS TAXPAYER ID USE THIS BANK ACCOUNT: Off |
| IF NO PLEASE EXPLAIN 1: |
| IF NO PLEASE EXPLAIN 2: |
| SECTION IV AUTHORIZATION FOR DIRECT DEPOSIT SET UP CHANGE OR CANCEL: Off |
| EXISTING ACCOUNT NUMBER: |
| PRINTED NAME: |
| TITLE: |
| DATE: |
| ACCOUNT NUMBER: |
| ROUTING NUMBER: |
| TAXPAYER ID: |
| ROUTING NUMBER_2: |
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