072606 ach authorization form1.xls

Town of Brookline, MA

Finance Division

Office of the Comptroller

Automated Clearing House (ACH) Vendor Payments

Electronic Payments save Time and Money

HOW ACH Payments benefit Vendors

Vendors that regularly do business with the Town of Brookline can receive their payments more quickly when using the

ACH process. To do this they must supply the banking information necessary to direct funds to one checking or savings

account and confirm their taxpayer ID to the Town. Following their first ACH payment, a letter will be sent to the Vendor

confirming the payment and verifying the accuracy of the electronic payment made by the Town. Additional ACH

payments will not be remitted until this confirmation has been returned to the Town of Brookline’s Comptroller.

Vendors should work with their financial institutions to determine:

• If the financial institution is able to provide the required remittance information (whether they have CTX

capabilities) – Per NACHA Ruling, financial institutions must make payment –related information available, upon

request, to their customers who receive payments through certain ACH formats, including CTX. Additionally, they

should work to ensure remittance information is passed along to their customers.

• How and when they will receive the remittance information from their financial institution

The benefits of receiving Vendor payments electronically include:

• Allowing the immediate availability of funds

• Eliminating the possibility of mail and deposit delays

• Eliminating the possibility of lost, stolen or misplaced checks

• Reducing the possibility of fraud

• Producing payments that are fully traceable through the NACHA system

Effective September 1, 2006, vendors that are regularly doing business with the Town of Brookline, MA , may be

considered for ACH Payments

ACH is an alternative to issuing checks to vendors. The New England Automated Clearing House (NEACH) serves as the

clearing house and processes electronic payments to the vendors’ bank accounts.

This electronic payment method will enhance our current payment program and improve overall payment service.

NEACH will usually make the electronic (ACH) payments available to vendors one banking business day after the date

that the ACH payment information is transmitted by the Town to their servicing bank.

After completing a simple set-up procedure, including a “prenote” (test record sent by the Town through their servicing

bank to NEACH and the vendor’s financial institution) test, qualifying vendors will receive ACH payments with detailed

supporting addendum records that will assist vendors in identifying the payments. Vendors should contact their financial

institution to ensure that the addendum records with be available to them if there is the possibility of multiple invoices

being paid in the same transmission. The Town uses CTX format to provide the servicing banks with the addendum

records when transmitting the payments.

Procedures

Vendors who wish to receive ACH payments must complete and return one Vendor ACH-EFT Application form

(ACHAUTH0706). For specific questions regarding this form, please call (617) 730-2036. For a downloadable version

of the setup information and 2 page form, please go to XXXXX and select the ACH Information button.

The steps in the ACH payment cycle are:

1. The vendor (and vendor’s financial institution) completes both sides of the Vendor ACH-EFT Application form

and returns the original of the form to the Town’s Office of the Comptroller.

2. The Town’s Office of the Comptroller verifies the data, updates the Town’s Vendor master file and generates a

pre-note through NEACH to the Vendor’s bank.

3. After a successful pre-note (usually 15 days are required for verification), the vendor will be approved for ACH

payment processing.

4. Brookline Town and School departments submit vendor invoices to the Office of the Comptroller for processing.

5. After each check run, the Town’s Treasurer’s Office transmits a file with detailed ACH payment data to the Town’s

servicing bank. The Town’s servicing bank transmits the information to NEACH.

6. On the settlement date of the electronic payment, the vendor’s financial institution credits the vendor’s individual

account.

7. Following the first ACH payment, an ACH confirmation letter is sent directly to the vendor to verify the payment

was successfully transmitted to its account. This confirmation must be returned before any further ACH payments

will be made.

MAILING INSTRUCTIONS:

Complete side 1: sections A-D and side 2, sign both sides of the Vendor ACH-EFT Application.

Mail to :

Purchasing Office-ACH

Brookline Town Hall-4

floor

333 Washington Street

Brookline, MA 02445

Incomplete forms or those lacking appropriate signatures on either side will not be processed and will be

returned to you for completion

TOWN OF BROOKLINE, MA ACHAUTH0706 Page 1 of 2

ENDOR ACH-EFT APPLICATION Complete both sides of form

SECTION A: TO BE COMPLETED BY SUBMITTING VENDOR - See A1 Below

DESCRIPTION

□ NEW □ CHANGE □ CANCEL

TAXPAYER ID TYPE (CHECK ONE AND INDICATE CORRECT NUMBER IN SPACE BELOW)

VENDOR NAME (30 CHARACTERS MAX) LEGAL NAME OF ENTITY OR INDIVIDUAL (30 CHAR MAX) (see (A1) below

ADDRESS TELEPHONE NUMBER WITH AREA CODE

(__ __ __ ) __ __ __ - __ __ __ __

CITY STATE ZIP CODE

__ __ __ __ __ __ __ - __ __ __ __

VENDOR ACH CONTACT NAME VENDOR ACH CONTACT EMAIL ADDRESS VENDOR ACH CONTACT FAX NUMBER

(__ __ __ ) __ __ __ - __ __ __ __

SECTION B: TO BE COMPLETED BY SUBMITTING VENDOR & CERTIFIED BY FINANCIAL INSTITUTION

FINANCIAL INSTITUTION NAME (30 CHARACTERS MAX) IF CHANGE PLEASE INDICATE PREVIOUS FINANCIAL INSTITUTION NAME

FINANCIAL INSTITUTION ADDRESS FINANCIAL INSTITUTION TELEPHONE NUMBER

(__ __ __ ) __ __ __ - __ __ __ __

FINANCIAL INSTITUTION CITY STATE ZIP CODE

__ __ __ __ __ __ __ - __ __ __ __

DEPOSITOR ROUTING NUMBER IF CHANGE PLEASE INDICATE PREVIOUS ROUTING NUMBER

DEPOSITOR ACCOUNT NUMBER IF CHANGE PLEASE INDICATE PREVIOUS ACCOUNT NUMBER

DEPOSITOR ACCOUNT TYPE (CHECK ONE)

□ 1 = SAVINGS OR □ 2 =CHECKING

SECTION C: FINANCIAL INSTITUTION CERTIFICATION - see C1) below

I certify the above Depositor Routing Number and Account Number to be true and accurate for the Vendor.

FINANCIAL INSTITUTION NAME Authorized Signature Date

SECTION D: VENDOR AUTHORIZATION- SEE D1) BELO

□

I (We) have attached a copy fields necessary to be included in the CTX addenda record (see D2) below.

□ I (We) hereby cancel my/our ACH/EFT authorization.

AUTHORIZED VENDOR REPRESENTATIVE OR STATE EMPLOYEE SIGNATURE Date

SECTION E: TOWN OF BROOKLINE USE ONL

I have reviewed the Vendor Information for Completeness and Accuracy and have entered the above information:

REVIEW SIGNATURE DATE ENTRY SIGNATURE DATE

General Instructions:

If the applicable sections of this application and the W9 are not complete, the application will not be processed by the Office of the Comptroller.

ACH Transactions will be effective approximately one month after the application is approved by the Office of the Comptroller

A1) Enter Legal Name of Entity or Individual as filed with the IRS:

Individual Enter your name (Last Name, First Name and Middle Initial as it appears on your IRS form 1040.

Sole Proprietor Enter Owner's name (Last Name, First Name and Middle Initial ) as it appears on your IRS form 941.

Corporation Enter your corporate name as it appears on your IRS form 941.

Partnership Enter your partnership name as it appears on your IRS form 1065.

Other Enter your entity's name as filed with the IRS

C1) Financial Institution Certification- Application must be signed by a representative of your bank after bank verification.

NOTE: IF THIS SECTION IS NOT COMPLETED, THE APPLICATION WILL BE RETURNED AND NOT PROCESSED

D1) VENDOR AUTHORIZATION- Application must be signed by an authorized representative or you (If an individual) before application can be processed by the Office of the Comptroller

D2)

Mailing Instructions:

Please complete both sides and return to Purchasing Office-ACH, Brookline Town Hall-4th floor, 333 Washington Street, Brookline, MA 02445

NOTE: Failure to obtain the Financial Institution Certification may result in delayed payments to vendor. Do not close an old account until the first transaction from the Town of Brookline has been

deposited into your new account.

APPROVED CTX ADDENDA RECORD FORMAT: if your Treasury department has data that must appear in the CTX Addenda records to properly credit ACH payments to our account, check the

appropriate boxes in section D and attach a detailed description of the fields, together with a contact name and telephone number should we have questions.

□ 1 = FEIN-Federal Employer ID # __ __ - __ __ __ __ __ __ __ OR □ 2 =SOC SEC# __ __ __ - __ __ - __ __ __ __

This authorization is to remain in full force and effect until the Town of Brookline, MA, Office of the Comptroller, has received written notification from me (or either of

us) of its termination in such time and in such manner as to afford the Town of Brookline and the financial institution a reasonable opportunity to act on it.

I (We) hereby authorize the Town of Brookline, MA, to initiate credit entries to my (our) account and to initiate, if necessary, debit entries and adjustments for any credit

entries in error to my (our) account indicated above at the depository financial institution named above, and to credit and if necessary debit the same such account. I

(We) acknowledge that the origination of ACH transactions to my (our) account must comply with the provisions of US law.

Changing Financial Institution or Depositor Account (within the Same Financial Institution- all deposits will continue to be deposited into your present account until the office of the Comptroller has been notified in

Writing that you have changed your banking information. With notification, you will need to submit a new Vendor ACT/EFT Application making sure to check the appropriate "CHANGE" box at the top of the form,

and completing the applicable fields on this form.

Form W-9

(Rev. October 2018)

Department of the Treasury

Internal Revenue Service

Request for Taxpayer

Identification Number and Certification

▶

Go to www.irs.gov/FormW9 for instructions and the latest information.

Give Form to the

requester. Do not

send to the IRS.

Print or type.

See Specific Instructions on page 3.

1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the

following seven boxes.

Individual/sole proprietor or

single-member LLC

C Corporation S Corporation Partnership Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership)

▶

Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check

LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is

another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that

is disregarded from the owner should check the appropriate box for the tax classification of its owner.

Other (see instructions)

▶

4 Exemptions (codes apply only to

certain entities, not individuals; see

instructions on page 3):

Exempt payee code (if any)

Exemption from FATCA reporting

code (if any)

(Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.) See instructions.

6 City, state, and ZIP code

Requester’s name and address (optional)

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid

backup withholding. For individuals, this is generally your social security number (SSN). However, for a

resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other

entities, it is your employer identification number (EIN). If you do not have a number, see How to get a

TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and

Number To Give the Requester for guidelines on whose number to enter.

Social security number

– –

Employer identification number

–

Part II Certification

Under penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue

Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am

no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because

you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,

acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments

other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.

Sign

Here

Signature of

U.S. person

▶

Date

▶

General Instructions

Section references are to the Internal Revenue Code unless otherwise

noted.

Future developments. For the latest information about developments

related to Form W-9 and its instructions, such as legislation enacted

after they were published, go to www.irs.gov/FormW9.

Purpose of Form

An individual or entity (Form W-9 requester) who is required to file an

information return with the IRS must obtain your correct taxpayer

identification number (TIN) which may be your social security number

(SSN), individual taxpayer identification number (ITIN), adoption

taxpayer identification number (ATIN), or employer identification number

(EIN), to report on an information return the amount paid to you, or other

amount reportable on an information return. Examples of information

returns include, but are not limited to, the following.

• Form 1099-INT (interest earned or paid)

• Form 1099-DIV (dividends, including those from stocks or mutual

funds)

• Form 1099-MISC (various types of income, prizes, awards, or gross

proceeds)

• Form 1099-B (stock or mutual fund sales and certain other

transactions by brokers)

• Form 1099-S (proceeds from real estate transactions)

• Form 1099-K (merchant card and third party network transactions)

• Form 1098 (home mortgage interest), 1098-E (student loan interest),

1098-T (tuition)

• Form 1099-C (canceled debt)

• Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident

alien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might

be subject to backup withholding. See What is backup withholding,

later.

Cat. No. 10231X

Form W-9 (Rev. 10-2018)