EPA Filter Form 2016 v8 (P)

Electronic Payment Authorization (EPA) Filter Form
Datasheet for Authorizing ACH Debit Entries
Date this Form is Being Submitted to KeyBank: _______________
(REQUIRED)
KEYBANK CLIENT (TRANSACTION RECEIVER) INFORMATION
Functional Contact Name:
Company Name:
Phone Number:
Account for EPA Service:
Fax Number (Optional):
ACH Routing Number:
Authorized Client Signature:
Email Address:
(REQUIRED)
TRANSACTION ORIGINATOR INFORMATION (UP TO 4 AUTHORIZATIONS)
Complete
Payment
Information
I want to:
Single or Recurring
Authorization:
(see note above)
• A Single/Exact Authorization is valid one time only for the exact dollar amount authorized below.
• A Recurring/Maximum Authorization will allow multiple transactions as long as they are each for less than (or equal to) the dollar amount authorized.
• Each Company ID may only be authorized for ONE Single/Exact and ONE Recurring/Maximum amount at any given time.
Add
Modify*
Delete**
Add
Modify*
Delete**
Add
Modify*
Delete**
Add
Modify*
Delete**
an authorization for the
an authorization for the
an authorization for the
an authorization for the
Company ID below.
Company ID below.
Company ID below.
Company ID below.
Single/Exact
Recurring/Maximum
Single/Exact
Recurring/Maximum
Single/Exact
Recurring/Maximum
Single/Exact
Recurring/Maximum
Company Name
Company ID
*Dollar Amount:
$
$
$
$
*Expiration Date
(Optional)
* To modify a previously authorized payment, enter the modified dollar amount and/or expiration date.
** Delete requests must be received one business day prior to debit date in order to be processed.
Check this box if you are submitting this form based on a notification you received from
KeyBank. Please include the notification when submitting this request, if possible.
This authorization allows KeyBank to pay the above ACH entities from
the account indicated. The authorization will remain in effect until the
expiration date or until ACH Operations receives and processes a
request to delete the authorization.
Comments/Special Instructions:
Notes:
•
To ensure your ACH Electronic Payment Authorization (EPA) Filter Form is processed promptly, please complete this form in its entirety and fax it to 866-913-8052 by
3:00PM Eastern Time. Requests received after 3:00PM Eastern may not be processed until the following banking day.
•
Requests with a valid Digital Signature may be emailed to [email protected] instead of faxing.
•
Please see Page 2 for additional instructions
©2016 KeyCorp. KeyBank is Member FDIC. 160707-102428
KeyBank: Confidential
Updated 06/2016
Instructions for Completing the
Electronic Payment Authorization (EPA) Filter Form
All fields are required except where noted
1. KeyBank Client (Transaction Receiver) Information
a. Functional Contact Name: A contact at your company that ACH Operations can reach out to if necessary
regarding this form. Preferably the person submitting the form.
b. Phone Number: Direct line (if possible) for Functional Contact
c. Fax Number (Optional)
d. Authorized Client Signature
e. Company Name
f. Account for EPA Service
g. ACH Routing Number: May not be the same Routing Number listed on your check. The digital version of
this form contains a drop-down list of all applicable Routing Numbers. If this form was faxed to you, please
contact your Sales Officer or Relationship Manager to have a copy emailed to you.
h. Email Address: Used for confirmation notice or as additional point of contact if ACH Operations encounters
a problem processing your request.
2. Transaction Originator Information: Enter the following information for the Transaction Originator, the company
that you would like to create an EPA filter for. This will allow that company to debit your checking account via ACH.
You may enter information for up to four different authorizations per Filter Form.
a. Payment Information: State whether you are setting up a New authorization, Modifying an existing
authorization or Deleting an existing authorization
b. Single or Recurring Authorization: Check whether you are authorizing a Single transaction for an Exact
amount, or a Recurring transaction up to a Maximum amount.
c. Originator’s Company Name
d. Originator’s Company ID: This can be obtained from the company attempting to debit your account.
− A single company may have multiple Company ID numbers, each requiring a separate authorization.
− If the transaction is being authorized as a result of an EPA Reject / Retry report that KeyBank has
sent you, the Company ID can be obtained from that form as well.
− Please note that Company IDs are 10 characters in length and “space” is a valid character.
[ 12345678A], [12345678A ] and [12345 678A] are all different, potentially valid, Company ID
numbers. Please verify this information with the other company prior to submitting your request.
e. Dollar Amount to Authorize: State the dollar amount to be authorized for this Company ID number.
− To set up an unlimited Recurring/Maximum authorization, please enter $99,999,999.99.
− To Modify an existing authorization, enter the modified dollar amount
− To Delete an existing authorization, enter $0.00 or leave the field blank (Note: Delete requests must
be received at least one business day prior to the debit date to allow for processing time)
f. Expiration Date (Optional): If the transaction is being authorized as a result of an EPA Reject / Retry
report that KeyBank has sent you, an Expiration Date (if chosen) must be at least one business day after the
Retry Date shown on your notification.
Please fax the completed form directly to KeyBank ACH Operations at 866-913-8052 by 3:00 PM ET.
Digitally signed forms may be emailed to [email protected] instead of faxing.
If you need additional assistance completing the EPA Filter Form, please contact:
Your KeyBank Sales Officer or Relationship Manager, or
Commercial and Business Banking Center: (800) 821-2829, or
ACH Operations Customer Service: (800) 304-9856
©2016 KeyCorp. KeyBank is Member FDIC. 160707-102428
KeyBank: Confidential