Division of Administrative Payments

Agency Information
This information must be completed by the requesting agency.

Payee/Company Information
This information must be completed by the vendor. The Taxpayer Identification Number (TIN) must be provided on all future invoices with the intent to use for payment purposes as well as the collection and reporting of delinquent debt in accordance with the Debt Collection Improvement Act of 1996.

Financial Institution Information
This information can be completed by the vendor or the vendor's Financial Institution (FI). The following must be completed:

• Name and address of FI
• ACH Coordinator-A contact at the bank in the ACH Department, if applicable.
• Phone Number of the Bank Contact
• 9 Digit Routing Transit Number (RTN)--This number uniquely identifies any FI and is used to direct the payments to the designated receiving FI. The FI can provide this information.
• Depositor Account Title--Name of the account, if different from the vendor's name.
• Depositor Account Number--Vendor's Account Number
• Type of Account--Checking or Savings
• Signature & Title of Authorized Official-Signature from someone who authorizes SSA to have this FI information for deposit of payments. Could be vendor or FI personnel.
• Telephone Number-Telephone number of the person who signed the form.

After the agency receives this information, a zero dollar entry will be processed to verify accurate bank information. There is an 11day waiting period for verification. After positive verification, your payments will be submitted by direct deposit. You must notify the agency if there are any changes in your bank information.