RF Adapted 10/07
ACH Payment Enrollment Form
Type of Transaction:
NEW
CHANGE
CANCEL
SECTION 1 (To be completed by the supplier.) Please Print!
Supplier Name
SSN , TIN or Employee id:
Telephone Number:
Name & Address of Financial Institution:
Account Type:
(Select One)
Checking Savings
Bank Routing Number: (Contact your Financial Institution for this information)
Account Number: (Please VERIFY with your Financial Institution!)
Supplier
Certification
I certify that I have read and understood the lower portion of this form. By signing and/or submitting this form, I authorize payments to be
sent to the financial institution named above and to be deposited to the designated account.
Signature:
Date:
Email Address:
Please be sure to provide email address. Email address is
required for remittance advice
SECTION 2
(To be signed by supplier or delegate to CANCEL payment via ACH).
Signature:
Date:
PLEASE READ THIS CAREFULLY
The information on this form is confidential and is required to process payment data from the Research Foundation of SUNY to
the financial institution and/or its agent. Failure to provide the requested information may delay or prevent receipt of payments
through the ACH program
.
Cancellation of ACH Payments:
Payments will be made electronically via ACH until cancellation by the Research Foundation or the supplier.
Cancellation by the Research Foundation: ACH payments will be canceled on the effective date of any of the following:
·
Change of financial institution or account information
·
Change of the supplier to inactive status.
Cancellation by the Supplier: You may stop receiving payments via ACH at any time by completing a new ACH Payment Enrollment
Form. On a new form, check the Cancel box, fill in supplier name, Social Security or Tax Id number, account number and account type,
then sign and date the form in Section 2.
Change in Financial Institution:
To change the financial institution into which you deposit funds, you must first cancel your ACH payment (see above), then complete a new
enrollment form to start ACH payments with the new financial institution.
Responsibilities:
·
You are responsible for verifying (with your bank) the accuracy of your bank account number when your enrollment form is completed
·
You are responsible for notifying the Research Foundation if you change banks or account number. You must complete a new ACH Payment
Enrollment Form and begin the ACH payment process again.
·
You must complete a ACH Payment Enrollment Form to cancel that ACH payment (see above for cancellation instructions).
·
You are responsible for payment of any charges that may be incurred against your account as a result of receiving an ACH payment.
·
You must repay the Research Foundation of SUNY if an overpayment occurs as the result of payment via ACH.
Miscellaneous:
·
A pre-notification will be processed upon receipt of this ACH Payment Enrollment Form to verify banking information is correct. If any
problems occur during the processing of the pre-notification supplier payments will continue as they were prior to completing the ACH
Payment Enrollment Form until corrections can be made.
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