ACH Payment Enrollment Authorization (for External Entities and Individuals)

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ACH PAYMENT ENROLLMENT AUTHORIZATION

PRIVACY ACT STATEMENT

The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). All information collected on this form is required under the provisions of 31 U.S.C. 3322 and 31 CFR 210. This information will be used by the Treasury Department to transmit payment data, by electronic means to vendor’s financial institution. Failure to provide the requested information may delay or prevent the receipt of payments through the Automated Clearing House Payment System.

Check One:

Faculty/Staff

Student(Individual)

Student Organizations/Sports Clubs

Vendor

Check One:

Direct Deposit(Initial Setup)

Direct Deposit Update

Payee/Company Information

Name:

M#/Taxpayer ID:

Address:

Contact Person (if different than payee):

Telephone:

Fax:

Please provide the name or e-mail address of the MTSU representative who provided the link to this form.

Financial Institution Information

Bank Name:

Bank Address:

Bank ACH Coordinator Name:

Telephone:

Exact Bank Account Title:

9 Digit Routing #:

Depositor Account #:

Type of Account:

Please attach a voided check, deposit slip, or bank statement screenshot of the account and routing number. The verification document should include the name of the person or organization, the financial institution name, and the full account number. Please note that bank/company letters/memoranda alone are not sufficient support. The attachment should be a .pdf or .jpeg image. Please note that .heic files are not compatible with this form and should not be attached.

If our payments to you (via ACH) are being forwarded from a U.S. financial institution to a financial institution in another country, this is considered to be an IAT transaction.

Please indicate whether these funds will qualify as an IAT entry:

Yes

I certify that information provided on this form is correct. I authorize Middle Tennessee State University to direct payments to the financial institution designated above and to initiate, if necessary, debit entries and adjustments for any credit entries in error. This authorization is applicable to all payments issued to the above - named payee by Middle Tennessee State University under the designated TIN or SSN.

Middle Tennessee State University does not discriminate against students, employees, or applicants for admission or employment on the basis of race, color, religion, creed, national origin, sex, sexual orientation, gender identity/expression, disability, age, status as a protected veteran, genetic information, or against any other legally protected class with respect to all employment, programs, and activites. The following person has been desinated to handle inquiries related to nondiscrimination policies for MTSU: Assistant to the President for Institutional Equity and Compliance. For additional information about these policies and the procedures for resolution, please contact Christy Sigler, Assistant to the President and Title IX Coordinator, Institutional Equity and Compliance, Middle Tennessee State University, Cope Administration Building 116, 1301 East Main Street, Murfreesboro, TN 37132; Christy.Sigler@mtsu.edu; or call (615) 898-2185. MTSU's policy of nondiscrimination can be found at http://www.mtsu.edu/titleix/.

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