Pennsylvania State System of Higher Education
Office of the Chancellor  Dixon University Center  2986 North Second Street  Harrisburg, PA 17110-1201
717-720-4000  www.passhe.edu
ACH Information Request Form
To enable the Pennsylvania State System of Higher Education, Office of the Chancellor, to pay
your invoices via the Automated Clearing House (ACH*) method and be notified via e-mail of
the payment, please complete this form and submit it to the Accounting Office per the
instructions below. If you have questions while completing the form, please contact Ms. Anna
Weber at 717-720-4121 or via email at aweber@passhe.edu.
Vendor Name (as it appears on your invoice):
______________________________________________
Banking Institution:
______________________________________________
Transit/Routing Number:
______________________________________________
Bank Account Number:
______________________________________________
Please indicate whether this is a savings or checking account:
____ Savings Account
____ Checking Account
Vendor Contact: ________________________
Title:
____________________________________
Phone Number: _________________________
E-mail:
____________________________________
E-mail Payment Notifications to: ____________________________________
Note: If your routing or account numbers change, please contact the Accounting Office
immediately at the phone number above.
_____________________________________________________________________________________________
Fax or mail the completed form to:
Fax: 717-720-4013
U.S. Mail:
Pennsylvania State System of Higher Education
Office of the Chancellor
Attention: Accounting Office
2986 North Second Street
Harrisburg, PA 17110
*At this time, we are not able to process wire transfers, only ACH payments.
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