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

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66 Instructions * Denotes a required field on the form 1. *Check the appropriate box at the top of the form: ■ New Add Request—Vendor would like to begin receiving payments via ACH. ■ Change/Update Existing Account—Vendor's account number, routing number, or remittance email address has changed. ■ Inactivate Existing Account—Vendor no longer wants to receive payments via ACH. 2. *Enter the vendor's Tax Identification Number or Social Security Number. 3. *Enter the Payee Name—The name of the person or business receiving payment. 4. *Enter the vendor's remittance address. The remittance address is the address printed on your invoice where payments should be sent. 5. *Enter the vendor's contact name, title, and phone number. 6. *Enter the vendor's financial information: ■ Financial Institution Name— Name of the financial institution. ■ Name on Account—The account owner's name. ■ Routing Number—Nine-digit number identifying the financial institution. ■ Account Number—The bank account number where the funds should be deposited. ■ Account Type— Is this a checking or savings account? Check the appropriate box. ■ Remit E-mail address - Enter the email address to which the remittance advices should be sent. 7. *For a new add request only, provide the following: ■ North Carolina State Agency Name—The state agency the vendor is doing business with. ■ North Carolina State Agency Contact Name—The vendor's contact person name at the state agency. ■ North Carolina State Agency Contact Email Address—The contact person's email address at the state agency. ■ North Carolina State Agency Contact Phone Number—The contact person's phone number at the state agency. NOTE: New add requests MUST include contact information for the state agency with which you are doing business. 8. Prior Financial Information —this is required if the vendor's bank account, routing number, or remittance email address has changed. • Financial Institution Name— Name of the prior financial institution. ■ Name on Account—The account owner's name. ■ Routing Number—Nine-digit number identifying the prior financial institution. ■ Account Number—The bank account number where the funds were being deposited. ■ Account Type— Is this a checking or savings account? Check the appropriate box. ■ Remit E-mail address - Enter the email address to which the remittance advices were being sent. 9. *Review all the information in the 3 attestation boxes located above the signature area. All 3 boxes must be checked—otherwise the form will not be processed. 10. *Print Name—Print the name of the authorized signee on the form. *Date— Date of signature. *Signature—The authorized signee's signature. *Phone Number—The authorized signee's phone number. Return to: OSC Support Services Center Address: 1410 Mail Service Center Raleigh, NC 27699-1410 Email: osc.support.services(cD_osc.nc.gov Please allow up to 30 days for processing. Revised February 2020