Finance Vendor Setup Form

FINANCE VENDOR SETUP FORM

Use this Vendor Setup Form to register your organization for electronic or check payments. Complete all fields accurately. Submission of false or misleading information may delay registration or result in liability for costs incurred by the payer. Provide supporting documentation where requested.

1. Vendor Identification

Entity Type: Corporation LLC Partnership Sole Proprietor Non-Profit Government Other

Taxpayer Identification Number (TIN) type: EIN SSN Other

TIN / EIN / SSN:

2. Business Address

3. Primary Contacts

4. Payment Method & Bank Information

Preferred Payment Method: ACH (electronic transfer) Check Wire Transfer

Account Type: Checking Savings

5. Payment Terms

Standard Payment Terms: Net 30 Net 45 Net 60 Due on receipt

Payment Effective Date:

6. Tax & Compliance

Backup Withholding Status: Vendor is subject to backup withholding Vendor is not subject to backup withholding

7. Terms, Authorization & Certifications

By completing and signing this form, Vendor certifies that the information provided is true, complete and accurate. Vendor authorizes the payer to rely on the information provided for purposes of establishing payment instructions. Vendor agrees to notify the payer promptly of any changes to account, tax, or remittance information.

Vendor warrants that it has the full right and authority to provide the banking information supplied and to authorize electronic transfers to such account. Vendor agrees to indemnify and hold harmless the payer for any losses, claims or expenses attributable to incorrect or fraudulent banking information provided by Vendor or failure to timely notify the payer of changes.

ACH Authorization: If ACH is selected, Vendor hereby authorizes the payer to initiate credit entries to the account provided. Vendor acknowledges that return of any ACH or other electronic payment may result in revocation of electronic payment privileges until the matter is resolved, and Vendor may be liable for costs and late fees as set forth in the payer's payment policy.

8. Certification Statement

Under penalty of perjury, Vendor certifies that the TIN provided is correct, that Vendor is not subject to backup withholding unless indicated above, and that Vendor is a U.S. person or other person as defined by applicable tax regulations where required. Vendor further certifies that Vendor will provide any additional documentation reasonably requested by the payer to comply with tax and payment regulations.

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