Accounts Payable ACH Authorization Form

(Direct deposit for vendors, employees, students, alumni, or former employees)

Complete this form to request non-payroll direct deposit of vendor or other payments to the bank account you specify below. ACH accounts will be set up for existing payee ID Types. Please sign the form and fax, email, mail it to the number specified at the bottom of the form.

Part I: Payee Information

Name______

Street Address______

City______State______Zip Code______

Phone______E-mail for Remittance ______

Employee or Student ID______Vendor Number______

Unit/Department Name______

Part II: Bank Information

Bank Name______

Bank Routing Number______(9-digits) Bank Account Number______

Account Type: ___ Corporate Checking___ Corporate Savings

___ Personal Checking*___ Personal Savings

*If you select personal checking, you must submit this form along with a copy of a voided check for the bank account specified above. In lieu of a voided check, you may send an account and routing verification from the bank. You may submit this information by fax or postal mail.

Part III: Authorization Agreement

I hereby authorize North Country Community College to initiate automatic deposits to my account at the financial institution named below. I also authorize North Country Community College to make withdrawals from this account in the event that a credit entry is made in error. Further, I agree not to hold North Country Community College responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in depositing funds to my account. This agreement will remain in effect until North Country Community College receives a written notice of cancellation from me or my financial institution, or until I submit a new ACH Authorization Form to the Business Office.

______Date ______

Authorized Signature

Fax this completed form to (518) 891-6562.

Accounts Payable, Business Office

North Country Community College

P.O. Box 89, 23 Santanoni Ave.

Saranac Lake, NY 12989

For assistance, contact Accounts Payable at (518) 891-2915 ext. 1221 or