Vendor ACH/Direct Deposit Authorization Form
City of Thomasville Accounts Payable
1. Please Check One:
NEW Direct Deposit CHANGE Direct Deposit CANCEL Direct Deposit
2. Vendor/Payee Information
Name:
Address:
Contact Person’s Name (if other than payee):
Telephone Number:
Email Address:
3. Financial Institution Information
Bank Name:
Bank Address:
Name on Bank Account:
Bank Phone Number:
Bank Account Number:
Nine-Digit Bank Routing/Transit Number (ABA):
Type of Account: Checking Savings
4. Approvals/Authorizations
-
I certify that the information provided on this form is correct, and I hereby authorize the City of Thomasville Accounts
Payable to electronically deposit payments to the bank account designated above. It is my responsibility to notify AP ([email protected]ov or
336-475‐5530) immediately if I believe there is a discrepancy between the amount deposited to my bank account and the amount of the invoice(s) paid. I
understand that I must notify City of Thomasville AP in writing immediately of any changes in status or banking information. I understand that this authorization
will remain in full force and
effect until City of Thomasville AP has received written notification requesting a change or cancellation and has had reasonable opportunity to act on it, which
should take no longer than seven (7) to ten (10) business days.
Print Name: Signature: Date: _
Important Information
Please return completed form via email: Megan.Widener@thomasville-nc.gov
For Office of Accounts Payable Use Only
Date Stamp
-
Received
AP Reviewed and Approved:
Date:
