AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFERSAuthorization Agreement for Electronic Funds Transfers • April 29th, 2021
[ ] WITHHOLDING [ ] SALES/USE [ ] CORPORATION [ ] INSURANCE PREMIUMS [ ] GASOLINE/MOTOR FUEL [ ] TANGIBLE PERSONAL PROPERTY [ ] BANK DEPOSITS [ ] PUBLIC SERVICE GROSS EARNINGS [ ] BANK EXCISE [ ] CIGARETTE STAMP [ ] CONSUMER USE TAX [ ] LITTER-BEVERAGE CONTAINER [ ] HOTEL TAX [ ] HEALTHCARE TAX [ ] LOCAL MEALS & BEV TAX [ ] ALCOHOLIC BEV IMPORT SERVICE FEE [ ] UNIFORM OIL RESPONSE & PREV [ ] WARWICK PARKING TAX [ ] PASS-THROUGH [ ] COMPOSITE INCOME TAX [ ] TOBACCO PRODUCTS [ ] E-911 $0.26 WIRELESS SURCHARGE [ ] E-911 $1.00 WIRELESS SURCHARGE [ ] E-911 $1.00 WIRELINE SURCHARGE [ ] TEL-COM EDUCATION ACCESS FUND [ ] OUTPATIENT HEALTHCARE FACILITY SURCHARGE [ ] HEALTHCARE IMAGING SERVICES SURCHARGE [ ] HARD-TO-DISPOSE MATERIAL TAX
Authorization Agreement for Electronic Funds TransfersAuthorization Agreement for Electronic Funds Transfers • December 15th, 2021
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFERSAuthorization Agreement for Electronic Funds Transfers • June 15th, 2012
[ ] WITHHOLDING [ ] SALES/USE [ ] CORPORATION [ ] INSURANCE PREMIUMS [ ] GASOLINE/MOTOR FUEL [ ] TANGIBLE PERSONAL PROPERTY [ ] BANK DEPOSITS [ ] PUBLIC SERVICE GROSS EARNINGS [ ] BANK EXCISE [ ] CIGARETTE STAMP [ ] CONSUMER USE TAX [ ] LITTER-BEVERAGE CONTAINER [ ] HOTEL TAX [ ] HEALTHCARE TAX [ ] LOCAL MEALS & BEV TAX [ ] ALCOHOLIC BEV IMPORT SERVICE FEE [ ] UNIFORM OIL RESPONSE & PREV [ ] WARWICK PARKING TAX [ ] PASS-THROUGH [ ] COMPOSITE INCOME TAX [ ] TOBACCO PRODUCTS [ ] E-911 $0.26 WIRELESS SURCHARGE [ ] E-911 $1.00 WIRELESS SURCHARGE [ ] E-911 $1.00 WIRELINE SURCHARGE [ ] TEL-COM EDUCATION ACCESS FUND [ ] OUTPATIENT HEALTHCARE FACILITY SURCHARGE [ ] HEALTHCARE IMAGING SERVICES SURCHARGE [ ] HARD-TO-DISPOSE MATERIAL TAX
Authorization Agreement for Electronic Funds TransfersAuthorization Agreement for Electronic Funds Transfers • February 18th, 2020
Vendor Name Remit to Address(if different from W-9) A/P Contact Person Email Address Phone Number Reason for Request(be specific)
Authorization Agreement for Electronic Funds TransfersAuthorization Agreement for Electronic Funds Transfers • December 15th, 2021
Authorization Agreement for Electronic Funds TransfersAuthorization Agreement for Electronic Funds Transfers • February 14th, 2012
All Automated Clearing House (ACH) Credit applicants must complete this form.Authorization Agreement for Electronic Funds Transfers • July 24th, 2018
Payment-related information must be sent in the standard National Automated Clearing House Association (NACHA) CCD + TXP format. Confirm with your bank representative that you and your bank can initiate ACH Credit transactions. We will mail instructions and formats to the EFT Contact person after we have received a completed authorization agreement and verified account status.
STATE OF RHODE ISLAND DEPARTMENT OF ADMINISTRATION DIVISION OF TAXATIONAuthorization Agreement for Electronic Funds Transfers • June 30th, 2003
Authorization Agreement for Electronic Funds TransfersAuthorization Agreement for Electronic Funds Transfers • June 19th, 2023
Please complete all information requested on this form and print. Sign and attach a voided check. Please return this form to:
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFERSAuthorization Agreement for Electronic Funds Transfers • January 26th, 2017
Authorization Agreement for Electronic Funds TransfersAuthorization Agreement for Electronic Funds Transfers • June 19th, 2023
Please complete all information requested on this form and print. Sign and attach a voided check. Please return this form to:
ContractAuthorization Agreement for Electronic Funds Transfers • September 16th, 2004
Please fill in the required fields online, before printing this Authorization Agreememt for Electronic Funds Transfers
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFERSAuthorization Agreement for Electronic Funds Transfers • October 17th, 2007
[ ] WITHHOLDING [ ] SALES/USE [ ] CORPORATION [ ] INSURANCE PREMIUMS [ ] GASOLINE/MOTOR FUEL [ ] TANGIBLE PERSONAL PROPERTY [ ] BANK DEPOSITS [ ] PUBLIC SERVICE GROSS EARNINGS [ ] BANK EXCISE [ ] CIGARETTE STAMP [ ] CONSUMER USE TAX [ ] LITTER-BEV CONTAINER [ ] HOTEL TAX [ ] HEALTHCARE TAX [ ] LOCAL MEALS & BEV TAX [ ] ALCOHOLIC BEV IMPORT SERVICE FEE [ ] UNIFORM OIL RESPONSE & PREV [ ] WARWICK PARKING TAX [ ] PASS-THROUGH [ ] COMPOSITE INCOME TAX [ ] TOBACCO PRODUCTS [ ] E-911 $0.26 WIRELESS SURCHARGE [ ] E-911 $1.00 WIRELESS SURCHARGE [ ] E-911 $1.00 WIRELINE SURCHARGE [ ] TEL-COM EDUCATION ACCESS FUND [ ] OUTPATIENT HEALTHCARE FACILITY SURCHARGE [ ] HEALTHCARE IMAGING SERVICES SUR
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFERSAuthorization Agreement for Electronic Funds Transfers • January 26th, 2000
FEDERAL IDENTIFICATION NUMBER: TYPE OF TAX: [ ] WITHHOLDING [ ] SALES/USE [ ] CORPORATION [ ] INSURANCE PREMIUMS [ ] GASOLINE/MOTOR FUEL [ ] TANGIBLE PERSONAL PROPERTY [ ] BANK DEPOSITS [ ] PUBLIC SERVICE GROSS EARNINGS [ ] BANK EXCISE [ ] CIGARETTE STAMP [ ] CONSUMER USE TAX
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFERSAuthorization Agreement for Electronic Funds Transfers • October 20th, 2022
Business Name Community Mental Health Association of Michigan (CMHAM) Tax ID / EIN 23-7402045 Street Address 507 S. Grand Ave City Lansing State Michigan Zip 48933 Phone 517-237-3146 Contact Name Regina MacDonald Email address for remittance rmacdonald@cmham.org Financial Institution Information Bank Name PNC Bank PO Box 3429Pittsburgh PA 15230-3429 Bank Routing # 041000124 Bank Account # 4233974146 Account Type Checking
