INSTRUCTIONS FOR REQUESTING PAYMENTS ELECTRONICALLY

Thank you for your interest in the Comptroller’s Vendor Direct Deposit (ACH) Program. Attached please find the Vendor Direct Deposit (ACH) Election Form for companies.

Please provide a completed Form W-9 (Request for Taxpayer Identification Number and Certification). This is a federal form that certifies the Taxpayer Identification Number (Federal Employer Identification Number or Social Security Number). This form allows us to make sure the information recorded in our Vendor File is current. You may access a fillable version of the form at www.irs.gov/pub/irs-pdf/fw9.pdf.

If the account type is a checking account, attach a voided check to the Vendor Direct Deposit (ACH) Election form. For accounts which you do not write checks from please include a letter from your bank which shows the ABA routing number, account number, and the name(s) on the account.

Keep a copy of the Vendor Direct Deposit (ACH) Election Form for your records. You must inform the ACH/VSS Unit of any changes to the information provided in writing to the below address or by email to osc.apdvf@ct.gov.

Please return completed forms to:

Office of the State Comptroller

Accounts Payable Division ACH/VSS Unit

55 Elm Street 6th Floor

Hartford, CT 06106-1775

If you choose to participate in this program:

Altered forms will not be accepted. You must submit a signed copy of this form along with a signed W-9 and one form of account verification (Voided Check, Deposit Slip, Bank Letter).

Upon approval, all vendor payments to you from the State of Connecticut that are issued by the Office of the State Comptroller Accounts Payable Division will be deposited electronically to the bank account you designate.

Remittance information may be viewed by accessing our accounting system through Vendor Self-Serve (VSS). Please visit our website at www.osc.ct.gov/vendor for information on the VSS system. When we receive your completed Vendor Direct Deposit (ACH) Election Form we will contact you regarding a User ID and password for VSS. Additionally, your financial institution may provide you with addenda information at the time of deposit. Contact your financial institution for more information on receiving electronic addenda.

Your financial institution’s ability to receive payments from us and properly credit your account will be verified with the transmission of a test transaction to your account. Further instructions will be sent to the contact email you list in the form’s VSS field. They will describe how to validate your ACH (EFT) test transaction. Failure to follow these instructions may delay your participation in this program. Once you have confirmed receipt of all test data, including accessing the remittance information in VSS, please contact the ACH/VSS Unit at (860) 702-3409 or by email at osc.apdvf@ct.gov.

Changes to your bank account information can only be authorized by the individuals listed on the Vendor Direct Deposit (ACH) Election Form. To request changes to the authorized individuals please contact the ACH/VSS Unit at osc.apdvf@ct.gov.

To process a change to your destination account number or financial institution you will need to submit another application package with the new information. Changes can take up to a week from the receipt of the form. To stop payment to a closed account immediately contact the ACH/VSS Unit by email at osc.apdvf@ct.gov.

When contacting us by email, always include ACH(EFT) in the subject line.

Thank you for your interest in this program.

Vendor Direct Deposit (ACH)	STATE OF CONNECTICUT

Election Form – Company	OFFICE OF THE STATE COMPTROLLER

Revised July 2013	Accounts Payable Division

55 Elm Street

Hartford, CT 06106-1775

email questions to osc.apdvf@ct.gov

Part 1 Vendor Information

Business Name:	FEIN/SSN:

Contact Name:	Phone:	(	)	Ext:

Title:	Fax:	(	)

Address:

City:	State:	Zip:

Contact Email:

Vendor Self-Serve (VSS) contact email(s):

Please list below the name of the individual(s) who are authorized to make changes to the bank account information.

(	)

Name	Phone	Email Address

(	)

Name	Phone	Email Address

Part 2 Account Information

Bank Name:

Routing & Transit #:(ABA#):	Account Type:	Account Change

Checking DDA Checking

Savings DDA Savings

Money Market Savings Account

Account #:

I hereby authorize the State of Connecticut (hereinafter “State”) to electronically deposit any payments made through the Office of the State Comptroller’s Accounts Payable Division to the bank account specified above. This authorization is to remain in full force and effect until the State has received written notification from me of its termination in such time and manner as to afford the State and the bank named above a reasonable opportunity to act upon it. In the event that the State notifies the bank that funds have been deposited to the company's account in error, I hereby authorize the State of Connecticut Office of the Treasurer to initiate a reversal of the payment in accordance with National Automated Clearing House Association (NACHA) regulations and direct the bank to return said funds to the State as soon as possible. In the event that for any reason, the bank is unable to return said funds to the State, I hereby authorize the State to recover those funds by any of the following methods: (1) deducting the amount of said funds from any future payments from the State until the amount of erroneous deposit has been recovered in full; (2) making written demand on the company for return of said funds, in which case the company hereby agrees to return said funds in full to the State within two (2) weeks of receipt of such written demand; or (3) any combination of methods (1) and (2) above. The company further agrees that if such funds are not repaid to the State, the company will be liable for all costs of collection, including reasonable attorneys’ fees incurred by the State in the collection of such funds, together with the maximum interest permitted by law.

I have read, understand, and agree to the above statement.

Signature:	Date:

This form along with a completed IRS Form W-9 and a voided check or preprinted deposit slip can be submitted by:

Fax - (860)702-3419	Email – OSC.APDVF@CT.GOV	or USPS to the address below.

Office of the State Comptroller, Accounts Payable Division ACH/VSS Unit, 55 Elm St. 6th Floor, Hartford, CT 06106-1775

If you are already enrolled

and are changing accounts

enter the last four digits of

the old account below.

Electronic Funds Transfer ACH (EFT) STATE OF CONNECTICUT

KPETIT

2020-11-24

Rowland, Haley

State of CT