PTC ACH ENROLLMENT FORM

PTC ACH ENROLLMENT FORM
VENDOR INFORMATION
Vendor Name:
Date:
Federal Taxpayer ID:
month/day/year
Account Status:
Set up New Account
Change Account Profile (already a vendor)
Email address for payment remittance advice:_____________________________________________
BANK INFORMATION
We would like our invoices paid via ACH and deposited in the following bank account:
Account Type:
Checking
Savings
Other>Please describe:
Bank Name:
Bank routing number*:
* ensure this is ACH and not FedWire routing number
Bank account number:
Bank address:
Street:
City:
State:
Zip:
Phone:
ACH FORMAT REQUESTED
ACH CCD
Payment will be transferred to the bank account listed above. A separate email will be sent
to the email address listed above detailing all of the remittance information.
ACH CCD+
Payment will be transferred to the bank account listed above. One line of addenda
information will be sent with the financial transaction through the bank identifying one of the
invoices paid with that amount. A separate email will be sent to the email address listed
above detailing all of the remittance information.
ACH CTX
Payment will be transferred to the bank account listed above. Addenda information will be
sent with the financial transaction through the bank identifying all invoices paid with that
amount. A separate email will be sent to the email address listed above detailing all of the
remittance information.
Please check with your bank regarding their ability to receive the ACH format requested above as well as your
bank's reporting services.
hereby authorizes and requests The Pennsylvania Turnpike Commission (PTC) to make
Vendor
payments by initiating entries to the account indicated on this form. All transfers will be sent via Automated Clearing House
(ACH). ACH transactions are processed on day one and credited to the account on the settlement date.
This authority is to remain in full force and effect until the PTC has received written notification from us of its termination in such
time and in such manner as to afford the PTC a reasonable opportunity to act on it.
The Vendor agrees that in the event of duplicate payment, overpayment, fraudulent payment, or payment otherwise made in
error, PTC may initiate a reversal of such payment, or otherwise debit the account shown above, to correct such payment.
THIS SECTION COMPLETED BY THE VENDOR
Approved by:
Date:
month/day/year
THIS SECTION COMPLETED BY THE PENNSYLVANIA TURNPIKE COMMISSION
Date Received:
Date Entered:
month/day/year
Entered by:
Approved by:
month/day/year