ACH/Direct Deposit Authorization Form - Center for Care Innovations
Payee Information
This form is used for submitting ACH payment information only and cannot be used for submitting wire instructions.
I am a [BLANK] of Center for Care Innovations
Please select...
Board Member
Employee
Grantee/Potential Grantee
Participant
Vendor
Volunteer
Payee Name
Does the organization/individual name match the bank account name?
Yes
No
Please note that this should be the name that your bank has on file associated with your bank account and this information should match to your account name displayed on your bank statements.
Does the name and address on the ACH form match the name and address on the W-9 form and invoice?
Yes
No
Upload W-9 form.
Upload W-9 form.
Address Line 1 (Address on file at your bank)
Address Line 2
City
State
Country
Postal Code
Contact Person's Name (if other than Payee)
Telephone Number
Enter in numeric values only. Do not enter dashes or parenthesis.
Email Address
When your payment is processed, you will receive a secure email message from Bank of America with an option to sign up for payment remittance notifications.
Comments
Financial Institution Information
Bank Name
Bank Address
Bank Account Number
Do not includes spaces or dashes. See sample check image below for where to find Account Number.
Your ABA number will be the 9-digits not already assigned to your account number and/or check number. See sample check below for an example. For ACH routing information, you will want to confirm with your banking institution whether or not their ACH number matches their ABA number.
Bank Routing (ABA) Number
9 digit routing number for electronic fund transfer. Do not enter spaces or dashes. Please see check image for a sample Routing (ABA) number.
Type of Account
Please select...
Checking
Savings
Please attach a voided check or bank authorization letter (
sample letter
) as confirmation of your ACH information.
Please note: This form uses an e-signature process. Once you provide your e-signature, you will then receive an email with a link to verify your e-signature. As many email services now pre-click links for security, this may count towards the verification. If you click the link and see an error page with language stating that you "Cannot verify signatory for a completed e-signature record", this means it's already been verified and successfully submitted.
Contact Information