Vendor ACH Authorization Request and Change Form

Complete all applicable fields below. This accessible HTML version is designed for keyboard navigation, screen reader support, and compact one-page printing.

Transaction Type

New Request Change Request Cancel Request Other

Bank Information

Account Type

Checking Savings

Requested Start Date

Name of Bank

Bank Phone Number

Routing Number (ABA)

Account Number

Bank Verification: Provide a bank letter which includes your name, bank routing number, and account number, or attach a voided check for the account above.

Alternatively, a bank representative may sign below, verifying the account details provided are accurate.

Bank Employee Signature

Title

Date

Authorization

I authorize the Fairfield County Auditor to initiate credit entries and, if necessary, debit and adjustment entries for any credit entry errors to my account indicated above. I also authorize the depository named above to credit and/or debit the same to said account. By authorizing this document, I am also attesting that I am an owner of the bank account indicated. This authorization will remain in effect until the Fairfield County Auditor has received my written notification of its termination.

I acknowledge it is my responsibility to inform Fairfield County of any termination or change of email address listed below. I understand that having my direct deposit advice emailed replaces the printed advice and that I am responsible for retaining the advices for future reference.

Vendor Name

Email Address

Last 4 Digits of SSN or EIN

Vendor Phone Number

I agree to the authorization statement listed above and attest I am an authorized agent for the named vendor. I acknowledge a Fairfield County representative will perform an independent verification prior to initiating this request in compliance with Auditor of State guidelines and bulletins related to cyber security protocols.

Requestor Signature

Date

Auditor’s Office Use Only

Submission Received Date

Vendor ID

Initials

Live Date