Agenda - 09-20-2022; 8-b - Acceptance of NC Agriculture Development and Farmland Preservation Trust Fund Grant

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Office of the State Controller Vendor Electronic Paytne&dorm Return to: OSC Support Services Center , ©New Add Request Address: 1410 Mail Service Center T , a: ©Change/Update Existing Account Raleigh,NC 27699-1410.. _ lf� Inactivate Existing Account Email: osc.support.services(&_osc.ne.,gov ', . '" -~ Denotes a required field Telephone: 919-707-0795 The State of North Carolina offers payees the opportunity to receive payments electronically through U.S. based banks. In addition to having the funds deposited electronically, you will also receive remittance information by e-mail. We require you to submit a copy of a voided check, bank statement, or a bank authorization letter on bank letterhead signed by a bank representative for account verification. *TAX ID#or SSN 5 *PAYEE NAME *REMITTANCE ADDRESS (AS PRINTED ON STREET SUITE/ROOM# YOUR INVOICE) CITY STATE ZIP CODE *CONTACT NAME&TITLE PHONE NUMBER NEW FINANCIAL INFORMATION *FINANCIAL INSTITUTION NAME: *NAME ON ACCOUNT: *NEW ROUTING NUMBER: *NEW ACCOUNT NUMBER: *ACCT TYPE: Checking F Savings *REMIT E-MAIL ADDRESS New add requests MUST include contact information for the state agency with which you are doing business. *North Carolina Agency Name: *North Carolina Agency Contact Name: *North Carolina Agency Contact Email Address: *North Carolina Agency Contact Phone Number: PRIOR FINANCIAL INFORMATION (only required for updates) FINANCIAL INSTITUTION NAME: NAME ON ACCOUNT: ROUTING NUMBER: ACCOUNT NUMBER: ACCT TYPE: Checking Savings REMIT E-MAIL ADDRESS * ALL BOXES BELOW MUST BE REVIEWED AND CHECKED ❑ 1 acknowledge that electronic payments to the designated account must comply with the provisions of U.S. law, and the requirements of the Office of Foreign Assets Control(OFAC). I affirm the entire amount of the payment will not be transferred to a foreign bank account. I authorize the Office of the State Controller to initiate ACH payments, and if necessary, adjustments for any ACH payments in error, to the financial institution and account identified on the attached certification document. This authority will remain in effect until 1,the vendor, cancel it in writing or the authority is terminated by the NC Office of the State Controller. I have attached a copy of a current voided check,current bank statement,or a bank authorization letter on bank letterhead signed by a bank representative. *PRINT NAME: *DATE: *SIGNATURE: *PHONE NUMBER: Revised February 2020