2022-508-E-DEAPR-North Carolina Department of Agriculture and Consumer Services-Approval of NCADFP grant contract for matached funds in acquisition of conservation easement of Poteat family farm

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Revised February 2020 Office of the State Controller Return to: OSC Support Services Center Address: 1410 Mail Service Center Raleigh, NC 27699-1410 Email: osc.support.services@osc.nc.gov Telephone: 919-707-0795 Vendor Electronic Payment Form New Add Request Change/Update Existing Account Inactivate Existing Account *Denotes a required field 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 *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: 6-6000327 Orange County, North Carolina PO Box 8181 Hillsborough NC 27278 Gary Donaldson/CFO No change to Financial Information 5 DocuSign Envelope ID: 480AFBD4-654C-48FA-9CB8-F7C8D7E98DB2 9/28/2022Gary Donaldson