Fairfield County Auditor Finance Office

Vendor ACH Authorization Request and Change Form

D-2.2 (Revised July 2025)

Transaction Type

Select Transaction Type:

Bank Information

Name of Bank

Bank Phone Number

Routing Number (ABA)

Account Number

Account Type:

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

Alternative Bank Verification

A bank representative may sign below to verify account details.

Bank Employee Signature

Date

Employee Title

Authorization & Attestation

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, you are also attesting that you are an owner of the bank account(s) 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/change of email address listed below. I understand that having my direct deposit advice emailed replaces the printed device and that I am responsible for retaining the advices for future reference.

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.

Vendor Name

Last 4 digits of SSN or EIN

Email Address (for advice notifications)

Vendor Phone Number

Requestor Signature

Date

Internal Auditor Use Only

Vendor ID

Live Date