Vendor ACH Authorization / Vendor Direct Deposit Form Template

Paying Company: [Your Company Name]
Accounts Payable Contact: [Name/Email/Phone]
Vendor ID (Optional): [Vendor ID]
Date: [Date]

1. Vendor Information

1.1 Vendor Legal Name: [Vendor Name]
1.2 DBA/Trade Name (If Any): [DBA]
1.3 Tax ID (Last 4 digits only) (Optional): [____]
1.4 Business Address: [Address]
1.5 Primary Contact Name/Title: [Name/Title]
1.6 Email/Phone: [Email] / [Phone]

2. Payment Method Authorization

2.1 Vendor authorizes [Paying Company] to initiate ACH credit entries (direct deposit) to the account listed below for payment of approved invoices.
2.2 Payment Frequency (Optional): ☐ Weekly ☐ Biweekly ☐ Monthly ☐ Per invoice ☐ Other: [].
2.3 Remittance Advice Delivery: ☐ Email ☐ Portal ☐ Mail ☐ Other: [].

3. Banking Details (Handle Securely)

3.1 Bank Name: [Bank Name]
3.2 Bank Address (Optional): [Address]
3.3 Account Holder Name: [Name as on account]
3.4 Account Type: ☐ Checking ☐ Savings
3.5 Routing Number: [Routing]
3.6 Account Number: [Account No.]
3.7 Account Number (Last 4 digits for confirmation): [____]

4. Verification (Recommended)

4.1 Provide one of the following (recommended):
☐ Voided check (do not include blank checks)
☐ Bank letter confirming account/routing
☐ Micro-deposit verification (if available)
☐ Other verification: [Describe]

5. Changes to Banking Information (Anti-Fraud)

5.1 Any changes to banking details must be submitted in writing using this form and verified by [Paying Company] through a separate callback or verification step.
5.2 Change requests sent only by email may be rejected for security reasons.

6. Cancellation / Revocation

6.1 Vendor may revoke this authorization by providing written notice at least [__] business days before the next scheduled payment, unless otherwise required.

7. Data Handling (Optional)

7.1 Banking information will be used only for vendor payments, stored securely, and access will be limited to authorized personnel.

Signatures

Vendor Authorized Representative: [Full Name]
Title: [Title]
Date: [Date]
Signature: ___________________________

For Paying Company (Optional): [Name]
Title: [Title]
Date: [Date]
Signature: ___________________________