2017-604 Co. Mgr. - NC Dept. of Agriculture and Consumer Services for the Orange County Crop Fund

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Office of the State Controller Vendor Electronic Payment Form Return to:OSC Support Services Center �v� ""� '�� Email:osc.support.services(cr�osc.nc.gov- Address: 1410 Mail Service Center s Telephone: 919-707-0795 Raleigh,NC 27699-1410 ,, � °- -� E]New Add Request Fax: 919-981-5561 yy� c ua��- _ ❑Change Existing ePay Account For your convenience and benefit, the State of North Carolina offers payees the opportunity to receive future payments electronically, rather than by check. Your payments will be deposited into the checking or savings account of your choice. In addition to having the money deposited electronically,you also will be notified of the deposit either by fax or by e-mail. The fax or e-mail will provide you with all the information that would normally be on your check stub. To receive payments electronically,you must complete this form,attach a voided check,and return via mail,e-mail,or fax to the information listed above. PRINT the following information. FAX or E-MAIL ADDRESS for payment notification. (Place a check mark in front of the method that you prefer.) Payee Name: Required E-mail Address: Federal ID#/SSN#: If you would like to receive remittances via fax, please Payee Address for check the box below. Otherwise remittances will Applicable Accounts: be sent via E-mail. ❑ FAX Number: Bank Name: Print Name and Title: Bank Routing Number: Contact Phone Number: ❑ Checking Acct#: ❑ Savings Acct#: ATTACH VOIDED CHECK OR PROVIDE A BANK LETTER WITH ACH ROUTING/ACCOUNT INFO I acknowledge that electronic payments to the designated account must comply with the provisions of U.S. law, as well as the requirements of the Office of Foreign Assets Control(OFAC).Check one of the following: ❑ I affirm that, regarding electronic payments the State of North Carolina may remit to the financial institution for credit to the account that I have designated,the entire payment amount is not subject to being transferred to a foreign bank account. ❑ I affirm that, regarding electronic payments the State of North Carolina may remit to the financial institution for credit to the account that I have designated, the entire payment amount is subject to being transferred to a foreign bank account. I understand that any electronic payments that may be remitted to me may be labeled with "AT"as the standard entry class. I acknowledge that availability of funds credited to the account will be subject to my receiving financial institution's policies and procedures. I also understand that the remitting agency may elect to remit future payments to me via paper check instead of electronically. I authorize the Office of the State Controller to initiate direct deposit entries each pay period, and if necessary, adjustments for any direct deposit entries in error,to the financial institution and account identified on the attached certification document. I understand and accept the conditions of participation in the direct deposit program.This authority will remain in effect until I cancel it in writing. SIGNATURE: _7DATE: