OTHER-2022-048-NCADFP Grant Contract

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Office of the State Controller Vendor Electronic Payment Form Return to : OSC Support Services Center ,;, � ' ' ' �' , O New Add Request Address : 1410 Mail Service Center S' ' �: 0 Change/Update Existing Account Raleigh, NC 27699- 1410 Inactivate Existing Account Email : osc . support. servicesgosc . nc . 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 . e require you to submit a copy of a voided check , bank statement, or a bank authorization letter on bank letterhead si gned 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 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 I 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 I , 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