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Get Ach Enrollment Form Template 2012-2024

ER IDENTIFICATION NUMBER (EIN VERMONT VENDOR ID NUMBER (if available) or SSN) Section 2: Banking Information BANK NAME ADDRESS CITY ACCOUNT NUMBER ROUTING NUMBER (9 digits) ACCOUNT TYPE (check one) Checking STATE ZIP CODE Savings Section 3: Vendor Authorization I authorize the State of Vermont to initiate/change/cancel ACH credit entries to the above bank account, I further authorize the State of Vermont to reverse any payment made to this account in error. SIGNATURE PRINTED NAME Ple.

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