PAYEE / COMPANY INFORMATION

This form is used to establish Automated Clearing House (ACH) payments. When payments are made as a result of submitting this form, funds will be automatically deposited to the account indicated. A remittance advice will be emailed to the email address shown in the "Email Address for Remittance Advices" section. The email remittance advice will contain the same information that is listed on a check stub, i.e. invoice number, invoice date and invoice amount. Failure to provide the requested accurate information may delay or prevent the receipt of payments through ACH.

For questions regarding the completion of this form, call 240-777-8850 or send an email to APSupplierMaintenance.Finance@montgomerycountymd.gov

PAYEE NAME

SSN OR TAXPAYER ID NUMBER

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

By clicking on the “Submit” button below Vendor/Contractor acknowledges and agrees that it has reviewed and understands the Agreement with the County, and that it agrees to be legally bound by the terms and conditions of the Agreement.

TELEPHONE

EMAIL ADDRESS FOR REMITTANCE ADVICES

EMAIL ADDRESS

FINANCIAL INSTITUTION INFORMATION

NAME OF FINANCIAL INSTITUTION

ACCOUNT NAME

ACCOUNT NUMBER

ROUTING/ABA#

TYPE OF ACCOUNT

CHECKING

SAVINGS