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Instructions Denotes a required field on the for <br /> 1 . *Check the appropriate box at the top of the form : <br /> ■ New Add Request — Vendor would like to begin receiving payments via ACH . <br /> ■ Change/Update Existing Account — Vendor' s account number, routing number, or remittance email address <br /> has changed . <br /> ■ Inactivate Existing Account — Vendor no longer wants to receive payments via ACH . <br /> 2 . * Enter the vendor' s Tax Identification Number or Social Security Number. <br /> 3 . * Enter the Payee Name — The name of the person or business receiving payment . <br /> 4 . * Enter the vendor' s remittance address . The remittance address is the address printed on your invoice where <br /> payments should be sent . <br /> 5 . * Enter the vendor' s contact name , title , and phone number. <br /> 6 . * Enter the vendor' s financial information : <br /> ■ Financial Institution Name — Name of the financial institution . <br /> ■ Name on Account — The account owner' s name . <br /> ■ Routing Number — Nine-digit number identifying the financial institution . <br /> ■ Account Number — The bank account number where the funds should be deposited . <br /> ■ Account Type — Is this a checking or savings account? Check the appropriate box. <br /> ■ Remit E -mail address - Enter the email address to which the remittance advices should be sent . <br /> 7 . * For a new add request only , provide the following : <br /> ■ North Carolina State Agency Name — The state agency the vendor is doing business with . <br /> ■ North Carolina State Agency Contact Name — The vendor's contact person name at the state agency. <br /> ■ North Carolina State Agency Contact Email Address — The contact person 's email address at the state agency . <br /> ■ North Carolina State Agency Contact Phone Number — The contact person 's phone number at the state agency. <br /> NOTE; New add requests MUST include contact information for the state agency with <br /> which you are doing business . <br /> 8 . Prior Financial Information — this is required if the vendor' s bank account, routing number, or remittance email <br /> address has changed . <br /> ■ Financial Institution Name — Name of the prior financial institution . <br /> ■ Name on Account — The account owner' s name . <br /> ■ Routing Number — Nine-digit number identifying the prior financial institution . <br /> ■ Account Number — The bank account number where the funds were being deposited . <br /> ■ Account Type — Is this a checking or savings account? Check the appropriate box. <br /> ■ Remit E-mail address - Enter the email address to which the remittance advices were being sent. <br /> 9 . * Review all the information in the 3 attestation boxes located above the signature area . All 3 boxes must be <br /> checked — otherwise the form ill not be processed . <br /> 10 . *Print Name — Print the name of the authorized signee on the form . <br /> *Date — Date of signature . <br /> *Signature — The authorized signee ' s signature . <br /> * Phone Number — The authorized signee' s phone number. <br /> Return to : OSC Support Services Center <br /> Address : <br /> 1410 Mail Service Center <br /> Raleigh , NC 27699A410 <br /> Email : osc. support. services anosc . nc . gov <br /> Please allow up to 30 days for processing , <br /> Revised February 2020 <br />