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STATE OF TENNESSEE Mail the ORIGINAL form to …

• The Name, Business Name, and Federal Employer Identification Number (FEIN) or Social Security Number (SSN) on the Supplier Direct Deposit Authorization form must ...

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Text of STATE OF TENNESSEE Mail the ORIGINAL form to …

STATE OF TENNESSEE DEPARTMENT OF FINANCE & ADMINISTRATION SUPPLIER DIRECT DEPOSIT AUTHORIZATION (NOT WIRE TRANSFERS) Mail the ORIGINAL form to the address below. Mark the outside of the envelope CONFIDENTIAL . State of Tennessee Attn: Supplier Maintenance 21st Floor WRS Tennessee Tower 312 Rosa L Parks Ave Nashville, TN 37243 SECTION 1: TYPE OF REQUEST New Change Existing Account: Enter Existing Routing No: Existing Account No: SECTION 2: ACCOUNT HOLDER INFORMATION Name (as shown on your income tax return): Business Name, if different from above: Federal Employer Identification Number (FEIN): or Social Security Number (SSN): Enter the address that should be associated with the account number:: Address Line 1: Address Line 2: City: State: Zip Code: Contact Name: Telephone: Enter the email address to which the remittance advices should be routed: Email: SECTION 3: AUTHORIZATION Are payments deposited into this account subject to being transferred, in its entirety, to a financial institution outside of the United States? Yes No Account Type: Checking Savings Financial Institution Name: Routing Number: Account Number: I authorize my financial institution to verify any information provided on this form with the State of Tennessee. I also authorize the state to initiate credit entries and to initiate if necessary, debit entries and adjustments for any credit entries in error, to my account indicated above. This authorization will remain in effect until the state has received written notification of its termination and has adequate time to act upon the Signatory Printed Name: Authorized Signature: Date: SECTION 4: FINANCIAL INSTITUTION VERIFICATION I certify the account and routing numbers in Section 3 are for the above specified account holder and is signed by an authorized signatory on the account. Representative Name: Representative Signature: Title of Representative: Date: Business Fax Number: Business Phone Number: Mailing Address: City: State: Zip Code: FA-0825 (Rev. 4/16) RDA SW20STATE OF TENNESSEE DEPARTMENT OF FINANCE & ADMINISTRATION SUPPLIER DIRECT DEPOSIT AUTHORIZATION INSTRUCTIONS (NOT WIRE TRANSFERS) As a supplier to the state of Tennessee you are offered the security and convenience of having payments automatically deposited into your bank account. The Supplier Direct Deposit Authorization is required to process payments electronically. The information on this form is confidential and subject to verification by the state. The completed form must contain original signatures and be received by the state in a timely manner. Electronic signatures are not 1: TYPE OF REQUEST Check the appropriate : Initial set up of supplier direct Existing Account: Bank account information will not be changed unless the existing routing andaccount numbers c urrently on file with the state have been 2: ACCOUNT HOLDER INFORMATION The Name, Business Name, and Federal Employer Identification Number (FEIN) or Social Security Number (SSN)on the Supplier Direct Deposit Authorization form must match the W-9 submitted, or the information already on filewith the state. Enter the address that should be associated with the account number identified in Section 3. For example, if thebusiness has different locations, each with separate bank accounts, enter the address of the location to which thisaccount applies. If the account is to be added to multiple addresses, list each address on an additional sheet. Enter the contact information of an authorized signatory on the 3: AUTHORIZATION All fields in this section must be 4: FINANCIAL INSTITUTION VERIFICATION This section must be completed by the financial institution the ORIGINAL form to the address below. Mark the outside of the envelope CONFIDENTIAL . State of Tennessee Attn: Supplier Maintenance 21st Floor WRS Tennessee Tower 312 Rosa L Parks Ave Nashville, TN 37243 Cancellation of Direct Deposit To cancel direct deposit, mail a written request to the address above. The request must contain the payee s name, FEIN or SSN, routing and account numbers, that matches the information already on file with the state, and an original signature of an authorized signatory. Should you have any questions or need assistance, contact Supplier Maintenance at 615-741-9745.

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