CUSTOMER INFORMATION SHEET
CUSTOMER NAME
MAILING ADDRESS
CITY
STATE
ZIP
The following must be completed before the new ACH file will be accepted. If using ACH for multiple entries, please
complete an additional Customer Information Sheet for each ACH use.
Please select one: (Complete a new Customer Information Sheet for each additional ACH Entry)
NEW ACH ENTRY SET UP
ADDING ADDITIONAL ACH ENTRY (for existing ACH customers)
Method of ACH File Creation (Please select one)
Upload NACHA File
Import .CSV File
Manual Entry
Purpose of ACH Entry (Please select one)
ACH Debit (Ex: payments, utility bills, membership or HOA dues,
etc.)
ACH Credit (Ex: payroll, vendor or invoice payments, etc.)
Account to hold funds __|__|__|__|__|__|__|__|__|__|
Select one (SEC Code):
Business to Business (CCD)
Business to Consumer (PPD)
TEL Entry (attach TEL Addendum)
WEB Entry (attach WEB Addendum
ACH Company/Batch Header Record Information (Description of ACH Entry)
For .CSV and Manual Entry, please complete the following fields showing how this information should come across on the ACH Entry.
If uploading a NACHA file, please complete the following fields exactly how it’s entered into your software.
__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
COMPANY NAME – UP TO 16 CHARACTERS
1|__|__|__|__|__|__|__|__|__|
COMPANY ID – EIN (9 IN LENGTH)
__|__|__|
__|__|__|__|__|__|__|__|__|__|
SEC CODE – 3
COMPANY ENTRY DESCRIPTION – UP TO 10 CHARACTERS
__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|
COMPANY DISCRETIONARY DATA – UP TO 20 CHARACTERS (NOT REQUIRED)
The ACH limit set for this customer will be the amount allowed for initiation for an ACH file; the customer will not be
able to exceed this limit. Please specify below the daily ACH limit for this customer.
Requested Daily ACH Limit: $________________
ACH File Initiation Frequency (Please select one):
Daily
Weekly
Bi-Weekly
Semi-Monthly
Monthly
___________________________________
Customer Signature
Date
---------------------------------------------------------------------------------------------------------------------Bank Use Only:
ACH AGREEMENT SIGNED
CREDIT CHECK OF PRINCIPAL(S)
Credit Report (All New Requests)
Bank Reference:________________________________________
Other Reference:_______________________________________
Special Instructions:__________________________________________________________________________
___________________________________________________________________________________________
Electronic Banking Dept Approval Date ___|___|____
I hereby certify that the above information is true and correct.
___________________________________
EBS Management
Date
___________________________________
Bank President/Officer
Date
ALPINE BANK
ACH ORIGINATION AGREEMENT
This Agreement is made this _____ day of _______________, ______, by and between
________________________________ “The Customer” and Alpine “Bank”.
The Customer has requested that the Bank permit it to initiate electronic credit or debit entries for payment to
consumer accounts maintained at Alpine Bank and at other financial institutions, by means of the Automated
Clearing House (“the ACH”).
Now, therefore the Customer and Bank agree as follows:
1. The Customer acknowledges receipt of a copy of the current operating rules of NACHA, dated
_____________________. The Customer agrees to comply with the ACH Rules as well as future
updates and abide by the applicable laws of the state of Colorado and of the United States of
America. This includes, but is not limited to sanctions enforced by the Office of Foreign Assets
and Control (OFAC). It shall further be the responsibility of the Customer to obtain information
regarding such OFAC enforced sanctions.
2. The Customer will obtain written authorization for consumer entries and shall retain these
authorizations for a period no less than two (2) years after the revocation or termination of the
authorization. The Customer will comply with all the terms of the Electronic Funds Transfer Act
if applicable or Uniform Commercial Code Article 4.5A (UCC4A) if applicable and shall
otherwise perform its obligations under this Agreement in accordance with all applicable laws and
regulations
3. The Customer shall send prenotification (zero-dollar) entries (not mandatory); at least six (6) days
prior to initiating the first live (dollar) entry to a particular account. Such notice shall be provided
to the Bank in the format and on the medium provided in the NACHA rules. Should the
Customer receive notice that any such prenotification has been rejected by the Receiving
Depository Financial Institution (RDFI), the Customer will initiate no further entries to the
Receiver until such time as the Customer provides the RDFI with such authorization. At such
time, the Customer may initiate entries within the time limits provided in the ACH Rules
4. The Customer understands and agrees that ACH entries to a Receiver’s account where the
individual names does not match the account information will be posted based on the account
information provided in the ACH transaction, not based on the name, individual identification or
other information provided in the entry. It is the responsibility of the Customer to verify that the
individual signing the ACH debit or credit authorization is in fact entitled to use of the specified
account.
5. The Bank shall notify the Customer of any returns or notification of change entries received for the
Customer no later than two (2) business days after the receipt of the item. This notification may
be given by phone to an authorized representative of the Customer, or by fax or email if requested
by the Customer.
6. Upon receipt of the return items the Customer will cease transmission of said transactions until a
new authorization has been signed by the consumer or until corrections have been made.
7. Upon receipt of notification of change items, the Customer must make the correction within six (6)
banking days, or before the next transaction, whichever is later.
8. The Customer will provide files in the agreed upon medium. The Bank may reject files not
received in the specified format and medium.
9. Each entry or file shall be delivered to the Bank in accordance to Attachment A.
10. The Customer will maintain a settlement account with the Bank at all times during the term of this
Agreement. Funds will be held in the account indicated, on the day of origination, for the
amount equal to the file(s) originated.
11. The Customer will receive immediate funds for any electronic debit entries initiated by it no later
than the settlement date of the items. Provisions may be made for holding accounts to be
maintained for posting of any return debit items received, as stated in this agreement and the ACH
Rules
12. The Customer will promptly provide immediately available funds to indemnify the Bank if any
debit items are rejected or returned after the Bank has permitted the Customer to withdraw
immediately available funds, should funds not be available in the Customer’s accounts to cover the
these returned items.
13. If the Customer discovers that any entry it has initiated was made in error, it must notify the Bank
of the error within 24 hours. In such a case, the Bank will utilize its best efforts to initiate an
adjusting entry or stop processing of any “on-us” entry. Should the Bank be unable to stop the
entry from posting, or if it is too late to withdraw the item from the ACH Operator, the Customer
may initiate a reversal file to correct that entry, as provided for and abiding by the Rules.
14. Should a reversal be created for an individual entry or entries, as opposed to a complete file
reversal, the Receiver(s) of the entries must be notified of the reversal no later than the settlement
date of the reversing entry.
15. Should a reversal be created for a complete file reversal, the Customer must advise the Bank
within five (5) banking days of settlement.
16. In the event that the ACH Operator for any reason rejects any entries, it shall be the responsibility
of the Customer to correct and resubmit such entries. Should the file be rejected due to an error
caused by the Bank, the bank shall be responsible to resubmit the file. In such a case, the
Customer will supply sufficient information, upon request, to allow the Bank to recreate the entries
for up to five- (5) banking days after midnight of the settlement date.
17. The Customer will indemnify the Bank if it incurs any financial loss or liability (with respect to
any entries initiated by the Customer) due to the breach of any of the warranties of an Originating
Bank set forth in the ACH Rules, except those due to the negligence of the Bank. This includes
reimbursement by the Customer to the Bank of any fines imposed on the Bank due to breaches of
ACH Rules by the Customer.
18. The Customer agrees to pay the Bank for the services referred to herein at the prices set forth in
Attachment 3 attached hereto.
19. The Bank shall be responsible only for performing the services expressly provided for in this
Agreement and shall be liable only for its negligence in performing those services. The Bank
shall not be responsible for the Customer’s acts or omissions (including without limitation the
amount, accuracy timeliness of transmittal, or due authorizations of any entry received from the
Customers) or those of any person, including without limitation any Federal Reserve Financial
Institution or transmission or communications facility, any Receiver or receiving Depository
Financial Institution (including without limitation the return of the entry by such Receiver or
Receiving Depository Financial Institution), and no such person shall be deemed the Banks agent.
The Customer agrees to indemnify the Bank against any loss liability, or expense (including
attorney’s fees and expense) resulting from or arising out of any claim of any person that the Bank
is responsible for any act or omission of the Customer, or any other person described in this
paragraph
20. In no event shall the Bank be liable for any consequential, special, punitive or indirect loss or
damage which the Customer may incur or suffer in connection with this Agreement, including
without limitation, loss of damage from subsequent wrongful dishonor resulting from the Bank’s
acts or omissions pursuant to this Agreement.
21. Without limiting the generality of the forgoing provisions, the Bank shall be excused from failing
to act or delay in acting if such failure or delay is caused by legal constraint, interruption of
transmission or communication facilities, equipment failure, war, emergency conditions or other
circumstances beyond the Bank’s control. In addition, the Bank shall be excused from failing to
transmit or delay in transmitting an entry if such transmittal would result in the Bank having
exceeded the limitation upon its intro-day net fund position established pursuant to present of
future Federal Reserve guidelines or which results in the Bank violating any provision of any
present or future risk control program of the Federal Reserve or any rule or regulation of any other
United States governmental regulatory authority.
22. Subject to foregoing limitations, the Bank’s liability for loss shall be limited to general monetary
damages in the amount not to exceed the total amount paid by the Customer for the applicable
ACH service, as performed by the Bank under this Agreement for the preceding 30 calendar days.
23. Notwithstanding any other provision to the contrary, in the event of default under the terms of this
Agreement by the Customer, the Bank shall have all rights and remedies available at law or in
equity.
24. The Customer and the Bank shall comply with the security procedures described in Attachment 2
(Security). The Customer acknowledges that the purpose of the security procedure is for
verification of file authenticity and not to detect errors within the transmitted file or individual
transactions. No security procedure for detection of any such error has been agreed upon between
the Customer and the Bank.
25. From time to time, the Bank may amend any of the terms and conditions contained in this
agreement. Such amendments shall become effective upon receipt of notice to the Customer, or
as stated in the notice to the Customer.
26. This agreement is terminable upon 10 days written notice by either party, provided that applicable
portions of this Agreement shall remain in effect with respect to any entries initiated by the
Customer prior to such termination.
27. This agreement shall be construed in accordance with and governed by the laws of the State of
Colorado and the NACHA rules.
28. Any other agreement between Customer and Bank relating to Customer’s financial transactions
with Bank (including, but not limited to, any signature card, account agreement or electronic funds
transfer) shall be superseded to the extent of any inconsistency or conflict between its terms and
terms of this Agreement, and the terms of this Agreement shall control.
Federal law, the Unlawful Internet Gambling Enforcement Act of 2006, and implementing
regulations prohibit commercial bank customers from receiving deposits of any kind relating to the
operation of an illegal Internet gambling business. Alpine Bank must enforce these regulations
accordingly and the Customer agrees to comply with such laws and regulations.
In WITNESS WHEREOF, the undersigned have duly executed the Agreement by their duly authorized
officers.
Customer Name:______________________________________________
Name:
Signature:
______________________________________________
______________________________________________
Title:
______________________________________________
Date:
______________________________________________
Personal Guarantee
For good and valuable consideration, the receipt and sufficiency of which is acknowledged, the
undersigned individual(s) hereby unconditionally guarantee each and every obligation of the customer under
the Alpine Bank ACH Agreement between Alpine Bank and ______________________________________,
as the customer, to which this is attached. In addition, the undersigned unconditionally agrees to indemnify
the Bank of any loss of any kind that the Bank may incur as a result of any fraudulent, improper or
unauthorized files that may be opened or transactions that may be implemented or initiated in the customer’s
name under the terms of the Agreement. This personal indemnity shall include any and all damages or cost
sustained by the Bank, including without limitation reasonable attorney’s fees, and shall include
indemnification from and against any claims made by third parties against the Bank arising out of any
transactions under this Agreement.
________________________________________________________
Signature
Date
________________________________________________________
Signature
Date
Alpine Bank/President-Manager
Name:
Signature:
________________________________________________
______________________________________________
Title:
_________________________________________________
Date:
_________________________________________________
ATTACHMENT 1
Transmission Location and Formatting Instructions
All files will be formatted in a NACHA or other preapproved format. Transmission specifications will be
established by ALPINE BANK.
Internet Transmission
The Customer will transmit files through its Alpine Cash Management, to Alpine Bank Operation Center via,
www.alpinebank.com and the Customer’s Online ID.
ACH PROCESSING DEADLINE
Processing Deadline for:
The following schedule is for use of the Customer to determine deadlines for sending
origination files to the Bank. Files received after these deadlines may not be guaranteed
delivery to the ACH Operator for settlement.
Credits-two day by 3:00 pm
Debits-one day by 3:00 pm
Must be received by the Bank
no later than two (2) banking days
prior to intended settlement date.
Must be received no later than one (1)
banking day prior to intended settlement
date.
HOLIDAY/SATURDAY-SUNDAY SCHEDULE
(Non-Processing Days)
New Years Day
Martin Luther Kings Birthday
Presidents Day
Memorial Day
Independence Day
Labor Day
Columbus Day
Veterans Day
Thanksgiving
Christmas
All Saturdays and Sundays
The Federal Reserve and Alpine Bank will be closed on these dates. Please keep in mind that ACH files cannot be delivered on
these dates, and transactions with effective dates on these holidays will have settlement deferred until the business day after the
holiday. To ensure that your transactions are received and posted to your customers/employees accounts in a timely manner, it is
necessary that Alpine Bank receive the files as follows:
If normal effective date falls on a holiday date, the effective day should be changed to the business day immediately prior
to the holiday for credits and immediately after the holiday for debits, and transmittals should be adjusted accordingly, (debits one
day prior, credits two days prior to new effective date.
ATTACHMENT 2
Security Procedures
All files will be formatted in a NACHA or other pre-approved format; transmission specifications will be established by
Alpine Bank.
Alpine Bank shall be entitled to rely on any written notice or other written communication believed by it in good faith to
be genuine and to have been signed by the Customer’s Authorized Representative, and any such communication shall be
deemed to have been signed by such person.
Internet Transmission
The Customer’s Authorized Representative will access the Internet Cash Management ACH system by utilizing the
prearranged log-on procedures, Alpine Online and Cash Management ID and Password.
Login Credentials
Your Alpine Online and Cash Management ID and Password are your keys to Alpine Online. It takes both identification
keys to gain access. No one representing Alpine Bank will ask for your Password. You should never write down your
password or give it to anyone who asks for it in an e-mail or by phone or anyone else who you do not want to have
access to your account. It is your responsibility to protect your online ID and passwords.
Logout Procedure
For your security, you should always logout at the end of each Alpine Online session. If you forget, Alpine Online will
automatically log out when you close the browser window or after a period of inactivity.
Identity Verification System
In the rare case that we detect any unusual or uncharacteristic activity, we will ask you to answer a question that only
you should know the answer to or receive a phone call to make sure that it's really you.
Each authorized user will choose his/her own security questions and should protect the answers to his/her security
questions. Each user should select questions and provide answers that are easy to remember, but hard for anyone else to
guess. Users should never write down security questions or answers or share them with anyone.
Dual Control
We recommend setting up your authorized users with Dual Control. Dual Control requires that two people login to
initiate an ACH transaction – one person to create the ACH file and the other to initiate it. This step helps to safeguard
from internal and external fraud, and helps detect any errors with transaction amounts.
Your Responsibilities
It is your sole responsibility to insure your personal computer and related equipment are compatible and capable of
operating in a manner that allows you to utilize Internet Banking Services. Your computer operating system and browser
should be kept up to date to ensure the highest level of protection, and should be kept free from Viruses, Trojans,
Spyware, and Malware. It’s also your responsibility to install current versions of virus detection software, firewall, and
spyware scanning tools to reduce computer infections. Keeping these tools updated is crucial in combating new and
existing threats. Visit www.alpinebank.com for more security tips.
The Customer is solely responsible for the accurate creation, modification, and deletion of the account information
maintained within the Customer Cash management ACH files and used for the Bank’s money transfer. The Customer
agrees to comply with written procedures provided by the Bank for the creation, maintenance, and initiation of the
Bank’s money transfers.
The Customer is solely responsible for access by its employees of the data files maintained on the Customer’s computer.
________________
Customer’s initials
ATTACHMENT 3
PRICE SCHEDULE
ALPINE BANK
Per Transmission or File (Internet) ________ $ 10.00
Account to access fees ___________________
(Same as Settlement Account on Attachment 4)
SPECIAL INSTRUCTIONS-BANK USE ONLY
__________________________________________
__________________________________________
Bank Officer Signature:______________________
_____________________________________________
Name
_____________________________________
Signature
__________________________
Date
Alpine Bank
Attachment 4 to ACH Origination Agreement
Originator Signature
This attachment is an addendum to the ACH Origination Agreement between
__________________________________________________ (Customer) and Alpine Bank.
Company Phone #____________________ Customer Tax ID #______________________
The Settlement Checking Account Number is _________________________.
(This account will be set as the settlement account for all offsets.)
ACTION:
ADD
CHANGE
REMOVE
Authorized Users Name:______________________________ Social Security Number:________________
Authorized Users Signature: _______________________________________________________________
Cash Management ACH Access (Please Specify below the ACH capabilities for this user)
YES
NO Each user may have individual ACH limits.
Set up/Edit ACH Batch/File
Dual Control
Initiate/Send ACH Batch/File
YES
YES
The users ACH amounts may not exceed the
Exposure Limit specified on the Customer
Information Sheet.
NO
NO ACH Amount Limit: $
Customer hereby represents and warrants to bank that the name(s) of the Authorized User(s) which are
authorized to initiate or set up ACH files/batches are correctly stated above. If at any time Customer wishes
to add or delete Authorized user(s), Customer will submit a new Attachment 4 form to the bank. Any
changes will supersede all previous Attachment4’s.
____________________________________
Company Name
_________________________________
Signature
_____________________________________
Name & Title of Company Officer*
_________________________________
Date
*Authorizing Company Officer must be a signer on the DDA Settlement Account.
Alpine Bank
Attachment 4 to ACH Origination Agreement
Originator Signature
This attachment is an addendum to the ACH Origination Agreement between
__________________________________________________ (Customer) and Alpine Bank.
Company Phone #____________________ Customer Tax ID #______________________
The Settlement Checking Account Number is _________________________.
(This account will be set as the settlement account for all offsets.)
ACTION:
ADD
CHANGE
REMOVE
Authorized Users Name:______________________________ Social Security Number:________________
Authorized Users Signature: _______________________________________________________________
Cash Management ACH Access (Please Specify below the ACH capabilities for this user)
YES
NO Each user may have individual ACH limits.
Set up/Edit ACH Batch/File
The users ACH amounts may not exceed the
Exposure Limit specified on the Customer
Information Sheet.
Dual Control
YES
NO
Initiate/Send ACH Batch/File
YES
NO ACH Amount Limit: $
Customer hereby represents and warrants to bank that the name(s) of the Authorized User(s) which are
authorized to initiate or set up ACH files/batches are correctly stated above. If at any time Customer wishes
to add or delete Authorized user(s), Customer will submit a new Attachment 4 form to the bank. Any
changes will supersede all previous Attachment4’s.
____________________________________
Company Name
_________________________________
Signature
_____________________________________
Name & Title of Company Officer*
_________________________________
Date
*Authorizing Company Officer must be a signer on the DDA Settlement Account.
Alpine Bank
Attachment 4 to ACH Origination Agreement
Originator Signature
This attachment is an addendum to the ACH Origination Agreement between
__________________________________________________ (Customer) and Alpine Bank.
Company Phone #____________________ Customer Tax ID #______________________
The Settlement Checking Account Number is _________________________.
(This account will be set as the settlement account for all offsets.)
ACTION:
ADD
CHANGE
REMOVE
Authorized Users Name:______________________________ Social Security Number:________________
Authorized Users Signature: _______________________________________________________________
Cash Management ACH Access (Please Specify below the ACH capabilities for this user)
YES
NO Each user may have individual ACH limits.
Set up/Edit ACH Batch/File
The users ACH amounts may not exceed the
Exposure Limit specified on the Customer
Information Sheet.
Dual Control
YES
NO
Initiate/Send ACH Batch/File
YES
NO ACH Amount Limit: $
Customer hereby represents and warrants to bank that the name(s) of the Authorized User(s) which are
authorized to initiate or set up ACH files/batches are correctly stated above. If at any time Customer wishes
to add or delete Authorized user(s), Customer will submit a new Attachment 4 form to the bank. Any
changes will supersede all previous Attachment4’s.
____________________________________
Company Name
_________________________________
Signature
_____________________________________
Name & Title of Company Officer*
_________________________________
Date
*Authorizing Company Officer must be a signer on the DDA Settlement Account.
Alpine Bank
Attachment 4 to ACH Origination Agreement
Originator Signature
This attachment is an addendum to the ACH Origination Agreement between
__________________________________________________ (Customer) and Alpine Bank.
Company Phone #____________________ Customer Tax ID #______________________
The Settlement Checking Account Number is _________________________.
(This account will be set as the settlement account for all offsets.)
ACTION:
ADD
CHANGE
REMOVE
Authorized Users Name:______________________________ Social Security Number:________________
Authorized Users Signature: _______________________________________________________________
Cash Management ACH Access (Please Specify below the ACH capabilities for this user)
YES
NO Each user may have individual ACH limits.
Set up/Edit ACH Batch/File
The users ACH amounts may not exceed the
Exposure Limit specified on the Customer
Information Sheet.
Dual Control
YES
NO
Initiate/Send ACH Batch/File
YES
NO ACH Amount Limit: $
Customer hereby represents and warrants to bank that the name(s) of the Authorized User(s) which are
authorized to initiate or set up ACH files/batches are correctly stated above. If at any time Customer wishes
to add or delete Authorized user(s), Customer will submit a new Attachment 4 form to the bank. Any
changes will supersede all previous Attachment4’s.
____________________________________
Company Name
_________________________________
Signature
_____________________________________
Name & Title of Company Officer*
_________________________________
Date
*Authorizing Company Officer must be a signer on the DDA Settlement Account.