Fairfield County Auditor Finance Office

Vendor Request and Change Form

D-2 Vendor Form (Revised 8/1/25) - Page 1 of 2

Choose One

New Vendor

Name Change

Address Change

ACH Change

To Be Completed by Requesting Department

Requesting Department

Vendor Number (leave blank if new)

Vendor Name

New Vendor Name (if applicable)

Corporate Address

Street Address

City, State, Zip

Remittance Address (if different)

Street Address

City, State, Zip

Address Change (if applicable)

Street Address

City, State, Zip

Phone Number

(Required if P.O. Box is provided above)

TIN No. (Employer/Tax ID)

Please Note: In order to comply with IRS reporting requirements, all new vendor and vendor changes must include an original and signed W-9 Form. Without this documentation, this request will not be accepted.

Fairfield County Auditor Finance Office

Vendor Request and Change Form

D-2 Vendor Form (Revised 8/1/25) - Page 2 of 2

Briefly describe the vendor activity:

To Be Completed by Submitting Department

Required forms available at: Accounts Payable / Vendor Forms - Auditor - Fairfield County, Ohio

Required forms are attached as follows:

OPERS Independent Contractor Acknowledgement

OPERS New Hire Reporting Form

IRS Form W-9

Fairfield County ACH Authorization

Proof of Independent Verification

Vendor contact:

Select Method of confirmation:

In Person

Phone

Other:

By signing this request, I affirm the following statements to be true: #1 I confirm compliance with Auditor of State Advisory (dated 3/9/24) and Redirect-AOS Payment Checklist, #2 I have confirmed with the vendor (in-person or via phone) the reflected information to be true and valid, and #3 I have evaluated any potential related party relationships and transactions.

NOTE: This form will NOT BE ACCEPTED without both required signatures.

Requestor Signature:

(Department staff member initiating this request)

Date:

Authorizer Signature:

(Department Head, Elected Official or their designee approving this request)

Date:

Deputy Auditor Use Only

Form 1099 Code

Date Keyed

Deputy Auditor Signature