Maryland Direct Deposit form GADX10Form (1).pdf

STATE OF MARYLAND

ACH/DIRECT DEPOSIT AUTHORIZATION

FOR VENDOR PAYMENTS

Email completed form to our secure email GADCSC@marylandtaxes.gov. See instructions on Page 2.

FORM WITH INCOMPLETE FIELDS WILL BE RETURNED. Form will NOT be processed without account verification. Vendor must submit a VOIDED check or BANK letter with completed form. NO starter checks, sample checks, counter checks, or deposit tickets accepted.

NEW CHANGE/UPDATE CANCEL

P ay ee In fo rm at io n

1. SSN or EIN (no hyphens)

2. Payee Name 3. Email address

4. Remittance Address: Street Address/PO Box

City State ZIP

5. Name of Person Filling Out Form 6. Title

7. Direct Phone Number Ext. 8. Business Phone Number Ext.

N ew

B an k In fo rm at io n

9. Bank Name

10. Bank Phone Number Ext. Bank Email Address

11. Account Type Checking Savings

12. Bank Routing Number 13. Bank Account Number

P ri o r

B an k In fo rm at io n Enter your old banking information only if you are changing or canceling your ACH:

14. Old Account Type Checking Savings

15. Old Bank Routing Number 16. Old Bank Acct Number

17. Attached with this completed form (choose one):

Voided Check - starter checks, counter checks, sample checks and deposit tickets are NOT acceptable. Address on voided check must match address on this form. If it doesn't, include a W-9 and most recent bank statement with this form.

Bank Letter - letter hand signed or with a verifiable digital signature by a bank representative confirming account name, account number, and ABA routing number.

18. How do you want Invoice Information to show on your Bank Statement?

***Vendor is responsible for any fees charged by your financial institution***

Standard format - CCD+ (DEFAULT) Example: "State of Maryland"

Detailed format - CTX* (multiple detail lines) Example: "State of Maryland and Invoice Information"

Detailed format - EDI* (full detail) Example: "State of Maryland and Invoice Information"

19. AUTHORIZATION BY VENDOR (or Vendor Representative) - REQUIRED I hereby certify that I am authorized to make the representations contained in this paragraph. I authorize the Comptroller and the Treasurer of Maryland to register the payee for automated clearing house (ACH) using the information contained in this registration form. I agree to receive all vendor payments from the State of Maryland by electronic funds transfer according to the terms of the ACH program. I agree to return to the State of Maryland any ACH payment incorrectly disbursed by the State of Maryland. I agree to hold harmless the State of Maryland and its agencies and departments for any delays or errors caused by inaccurate or outdated registration information or by the financial institution listed above.

Printed Name Title

Authorized Vendor Signature Date COT/GAD X-10 (Rev 03/23) Page 1 of 2 GAD Input By: STO Input By:

GAD Reviewed By: STO Reviewed By:

mailto:GADCSC@marylandtaxes.gov

INSTRUCTIONS FOR COMPLETING STATE OF MARYLAND

ACH/DIRECT DEPOSIT AUTHORIZATION FORM

GENERAL INSTRUCTIONS:

Please type or print clearly. Only the owner of the bank account or an authorized company official can make an ACH/ Direct Deposit request.

Only use this form if...

You are a vendor that is required to receive ACH/Direct Deposit payments or a vendor that receives paper checks now and wants ACH/Direct Deposit.

NEW: Select this if you are a vendor being paid by the State of Maryland by check and would like to get paid by ACH/direct deposit.

Student refunds, Lottery payments, DORS payments, Renters tax credits, and Restitution payments are NOT eligible for ACH.

CHANGE/UPDATE: Select this if you wish to change the bank account where your payments are sent. Do not close your old bank account until electronic payments are received in your new account.

CANCEL: Select this if you want to cancel (revoke) your prior ACH/Direct Deposit Authorization.

Online credit cards are NOT eligible for ACH transfer.

Payee Information Instructions

1. SSN/EIN (no hyphens) Enter your Social Security Number (SSN) or the Employer Identification Number (EIN). Enter the one which the State of Maryland uses to pay you currently.

2. Payee Name Enter the name of the individual or business that will be paid.

3. Email address Enter an email address where we can contact you for questions with this form.

4. Address, City, State ZIP Enter the street address or post office box, city, state & ZIP to where the payment information should be sent (e.g. remittance address).

5. Name of person filling out form Enter the name of the person to contact for any questions relating to this form.

6. Title Enter the title of the person completing this form. If it's yourself, enter Self.

7. Direct Phone Number/Ext Enter the telephone number/extension where we can contact you directly.

8. Business Phone Number/Ext Enter the business phone number and extension, if applicable. If you are an individual, enter your direct phone number again.

Bank Information Instructions

9. Bank Name Enter the name of your finanical institution (bank, credit union, savings & loan, etc.).

10. Bank Phone Number/Ext and Email Enter the phone number & email of your financial institution in case we need to contact them.

11. Account Type Select ONE account type, either checking or savings.

12. Bank Routing Number The routing number is the nine (9) digit bank identification number at the bottom of your check. If you are unsure, contact your financial institution.

13. Bank Account Number Enter the account number into which your payment will be transferred. If you are unsure, contact your financial institution.

14. Old Account Type Select ONLY IF you are changing your bank information or canceling your direct deposit.

15. Old Bank Routing Number* Enter ONLY IF you are changing your bank information or canceling your direct deposit.

16. Old Bank Account Number* Enter ONLY IF you are changing your bank information or canceling your direct deposit.

17. Voided Check or Bank Letter Attach either a Voided Check (with address) OR a signed letter from your financial institution to this form.

18. Invoice Information Select the amount of detail you want on your bank statement. The standard default will say "State of Maryland". Contact your financial institution for more information on the other formats, and if there are any fees associated with it.

19. Authorized by Vendor, Signature and Date Print or type vendor name. The vendor or authorized representative must sign & date the form.

Please send completed form and documentation to:

Secure email (preferred): GADCSC@marylandtaxes.gov

Fax: (410) 974-2309

Postal Mail: State of Maryland Comptroller of Maryland

ACH Registration

General Accounting Division, Room 205

P.O. Box 746

Annapolis, MD 21404-0746

Questions? Please contact Vendor Services:

Email: GADCSC@marylandtaxes.gov

Phone: 410-260-7813 or toll free at 888-784-0144

COT/GAD X-10 (Rev 03/23) mailto:GADCSC@marylandtaxes.gov mailto:GADCSC@marylandtaxes.gov