Instructions for Completing ACH Enrollment Form

 

Use these instructions to complete the ACH Enrollment Form to receive Supplier reimbursements via direct deposit. 

This form is also to be used for subsequent changes to bank information or to cancel direct direct deposit.

Note: This form is for AP payments only. Please check with your payroll department for information on payroll direct deposit. 

 

Completing the Form

The check image and the table below provide guidance on the information to enter for each field on the form.

image of a check

 

Field Name Entry Value
Section 1
Type of Transaction Check the appropriate box. For new enrollment NEW. For a change to information CHANGE or to cancel enrollment CANCEL.
Supplier Name Your name as it appears in the Supplier file.
SSN, TIN or Employee Id A unique identifier.
Telephone Your telephone number.
Name and Address of Financial Institution Name and address of your bank as shown on the sample check above.
Bank Routing Number 9 Digit Bank Routing Number as shown on the sample check above.
Account Type Check the appropriate account type checking or savings.
Account Number Your Account Number as shown on the sample check above.
Supplier Certification By checking the check box you agree to receive Supplier payments via direct deposit to your bank account.
Signature Your typed signature.
Date Date the form was completed.
Email A valid email address.
Section 2 (to be completed to cancel enrollment only)
Signature Your typed signature.
Date Date the form was completed.

 

Submitting the Form

Once all required fields are completed, press the “Submit Form” button to send the completed form to the Finance Office for processing. 

> Back to ACH Payment Enrollment Form