MECKLENBURG COUNTY
AUTHORIZATION AGREEMENT
FOR AUTOMATIC DEPOSIT (ACH CREDITS) OF MECKLENBURG COUNTY CHECKS
We hereby authorize the Mecklenburg County Finance Department to initiate credit entries to our account, as listed below, in the
financial institution named below and authorize the financial institution to credit the same to our account.
This authority is to remain in effect until revoked by us in writing to the Mecklenburg County Finance Department. Account changes
must be reported to the Mecklenburg County Finance Department thirty (30) days prior to the actual change.
Please complete the following information:
SECTIONS I: VENDOR INFORMATION
DATE: ______________________________________
VENDOR NAME: __________________________________________________________________________________
VENDOR ADDRESS:_______________________________________________________________________________
________________________________________________________________________________
FEDERAL IDENTIFICATION NUMBER:_______________________________________________________________
FISCAL OFFICER:__________________________________________________________________________________
SIGNATURE OF FISCAL OFFICER:___________________________________________________________________
CONTACT TELEPHONE NUMBER___________________________________________________________________
PAYMENT NOTIFICATION E-MAIL ADDRESS ________________________________________________________
NOTE: An e-mail notice of invoices being paid will be sent to the vendor when a payment is processed via ACH.
SECTION II: BANKING INFORMATION
DIRECT DEPOSIT TO BE MADE TO:
FINANCIAL INSTITUTION –
NAME: ____________________________________________________________
BRANCH: __________________________________________________________
ADDRESS: ___________________________________________________________
___________________________________________________________
TELEPHONE NUMBER: ___________________________________________________________
ROUTING & TRANSIT/ABA NUMBER: ___________________________________________________________
ACCOUNT NUMBER: ___________________________________________________________
TYPE OF ACCOUNT: CHECKING _____________________ SAVINGS________________________
Select the option in the event of an error in payment:
____ receive a correction via the ACH network
____ receive a telephone call to discuss correction of the overage
SECTION III: (TO BE COMPLETED BY MECKLENBURG COUNTY FINANCE)
DATE RECEIVED: ________________________ VENDOR NUMBER: ________________________
ENTERED TO SYSTEM: ____________________________
***ATTACH A VOIDED CHECK***