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Revised May 2018 <br />Instructions * Denotes a required field on the form <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 pa yments 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 />▪Agency Name – The state agency the vendor is doing business with. <br />▪Agency Contact Name – The vendor’s contact person name at the state agency. <br />▪Agency Contact Email Address – The contact person’s email address at the state agency. <br />▪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 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 />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 will 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 27699-1410 <br />Email: osc.support.services@osc.nc.gov <br />Please allow up to 30 days for processing. <br />DocuSign Envelope ID: F8ACCDE8-686F-4083-B46D-486310D8A869