Finance Vendor Information Form

Finance Vendor Information Form

Please complete this Vendor Information Form to establish or update vendor payment and tax records. Complete all applicable fields accurately. Submission of this form authorizes the company to rely on the information provided for payment and tax reporting purposes.

Vendor Identification

Tax ID Type: EIN SSN Other

Corporation LLC Partnership Sole Proprietor Nonprofit Government Other

Addresses

Primary Contacts

Accounts Payable / Invoicing

Payment Method & Banking Information

Preferred Payment Method: ACH / Direct Deposit Wire Transfer Check Credit Card

Late Payment Policy: Vendor agrees that past due invoices may be assessed interest and collection costs in accordance with the vendor agreement or applicable law. Late fee policy specified by vendor:

Account Type: Checking Savings

Attachments: I have provided a voided check or bank letter to verify account information. Voided check attached Bank letter attached

Tax & Reporting

Vendor certifies that the Tax Identification Number provided is correct and that the vendor is not subject to backup withholding unless indicated below.

Backup Withholding Status: Subject to backup withholding Not subject to backup withholding

W-9 Provided: Yes No

Certifications and Authorizations

By signing below, the vendor certifies that all information provided on this form is true, accurate and complete to the best of the signatory's knowledge. The vendor authorizes the company to initiate credit entries and, if necessary, debit entries and adjustments for any credit entries made in error to the bank account indicated for payment.

Vendor further agrees to notify the company in writing of any changes to the information on this form at least days prior to the effective date of such change. Vendor indemnifies and holds harmless the company from any loss resulting from incorrect information provided by vendor or from failure to provide timely notice of changes.

Effective Date:

Certification: I declare under penalty of perjury that the information provided on this form is true and correct. I am authorized to execute this document on behalf of the named vendor and to bind the vendor to the terms contained herein.

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