Form SFMS ACH-1 "Direct Deposit Authorization Form for State Wide Vendor/Employee Travel (Not Pers/Payroll)" - Oregon

What Is Form SFMS ACH-1?

This is a legal form that was released by the Oregon Department of Administrative Services - a government authority operating within Oregon. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 22, 2020;
  • The latest edition provided by the Oregon Department of Administrative Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form SFMS ACH-1 by clicking the link below or browse more documents and templates provided by the Oregon Department of Administrative Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form SFMS ACH-1 "Direct Deposit Authorization Form for State Wide Vendor/Employee Travel (Not Pers/Payroll)" - Oregon

1291 times
Rate (4.7 / 5) 77 votes
S t a t e o f O r e g o n
D i r e c t D e p o s i t A u t h o r i z a t i o n F o r m
For State Wide Vendor / Employee Travel (not PERS/Payroll)
RECOMMENDATION: For accuracy, type information or print legibly.
Only forms with original signatures are accepted (No faxes or copies)
-
Retain a copy for your records
SECTION A – PAYEE INFORMATION
Instructions are on Page 2
1. TYPE OF ACTION (Required)
2. SSN / FEIN / OR# (Social Security / Federal Employer Identification /
Oregon Employee Number – Only one ID number Required)
NEW (Start)
CHANGE
CANCEL (Stop)
3. PAYEE NAME AND MAILING ADDRESS (Required)
4. PHONE NUMBER (Recommended)
5. EMAIL ADDRESS (for payment notification - Required)
SECTION B – AUTHORIZATION - IMPORTANT! Please read and sign before submitting.
This form is used to authorize direct deposit to a checking or savings account.
Cancel account – To cancel this authorization, fill out a new form and check the cancel (STOP) box, sign and
date the form and mail as instructed on the back.
Change account – By selecting the “change” box and completing the form with new account information, or by
selecting the “cancel” box, you hereby revoke your previous authorization for direct deposit.
International transaction certification – I certify that the entire amount of my direct deposit is NOT ultimately
deposited into a financial institution outside the United States.
I certify that I have read and understand the information contained in this form. I acknowledge that the origination of
transactions to the authorized account must comply with provisions of Oregon and U.S. law. I certify that I am authorized to
enter into this agreement as the account holder.
1.
X
Signature of Account Holder (Required)
Print Name (Required)
Title (if company account) (Required)
Date (Required)
2.
X
Signature of Account Holder
Print Name
Title (if company account)
Date
SECTION C – FINANCIAL INSTITUTION INFORMATION (To be completed and signed by Financial Institution
Representative or SFMS will accept Agency Payroll Office signature for State Employees travel reimbursements.)
SAVINGS
CHECKING
PERSONAL
COMMERCIAL
1. ACCOUNT TYPE (1):
a.
b.
ACCOUNT TYPE (2):
c.
d.
(Required)
(Required)
2. ABA/BANK ROUTING NUMBER (Required)
3. DEPOSITOR ACCOUNT NUMBER (Required)
Memo _____[EXAMPLE]___________
_____________________
Location of account numbers are on bottom of your check:
123456789
2345678
9876
Routing number
Account number
Check #
4. FINANCIAL INSTITUTION NAME (Required)
5. NAME(S) AS THEY APPEAR ON ACCOUNT (Required)
6. FINANCIAL INSTITUTION ADDRESS (Required)
-
(Number and Street)
(City)
(State)
(Zip)
I have verified the account number above. This Financial Institution is ACH capable and will comply with NACHA rules.
(SFMS will accept Agency Payroll Office signature for State Employees travel reimbursements.)
7. Financial Representative’s Name (Printed
8. Signature of Financial Representative
9. Telephone Number
10. Date
or Typed - Required)
(Required)
(Required)
(Required)
SECTION D – FOR DAS/EGS/FBS/SFMS USE ONLY
1. Vendor No. and Mail Code
2. Pre-note Date
3. NACHA Format
4. Notes
PPD+
CCD+
https://www.oregon.gov/das/Financial/AcctgSys/Pages/ach.aspx
SFMS/ACH Forms
:
Form SFMS ACH-1 (Rev 10/22/20)
S t a t e o f O r e g o n
D i r e c t D e p o s i t A u t h o r i z a t i o n F o r m
For State Wide Vendor / Employee Travel (not PERS/Payroll)
RECOMMENDATION: For accuracy, type information or print legibly.
Only forms with original signatures are accepted (No faxes or copies)
-
Retain a copy for your records
SECTION A – PAYEE INFORMATION
Instructions are on Page 2
1. TYPE OF ACTION (Required)
2. SSN / FEIN / OR# (Social Security / Federal Employer Identification /
Oregon Employee Number – Only one ID number Required)
NEW (Start)
CHANGE
CANCEL (Stop)
3. PAYEE NAME AND MAILING ADDRESS (Required)
4. PHONE NUMBER (Recommended)
5. EMAIL ADDRESS (for payment notification - Required)
SECTION B – AUTHORIZATION - IMPORTANT! Please read and sign before submitting.
This form is used to authorize direct deposit to a checking or savings account.
Cancel account – To cancel this authorization, fill out a new form and check the cancel (STOP) box, sign and
date the form and mail as instructed on the back.
Change account – By selecting the “change” box and completing the form with new account information, or by
selecting the “cancel” box, you hereby revoke your previous authorization for direct deposit.
International transaction certification – I certify that the entire amount of my direct deposit is NOT ultimately
deposited into a financial institution outside the United States.
I certify that I have read and understand the information contained in this form. I acknowledge that the origination of
transactions to the authorized account must comply with provisions of Oregon and U.S. law. I certify that I am authorized to
enter into this agreement as the account holder.
1.
X
Signature of Account Holder (Required)
Print Name (Required)
Title (if company account) (Required)
Date (Required)
2.
X
Signature of Account Holder
Print Name
Title (if company account)
Date
SECTION C – FINANCIAL INSTITUTION INFORMATION (To be completed and signed by Financial Institution
Representative or SFMS will accept Agency Payroll Office signature for State Employees travel reimbursements.)
SAVINGS
CHECKING
PERSONAL
COMMERCIAL
1. ACCOUNT TYPE (1):
a.
b.
ACCOUNT TYPE (2):
c.
d.
(Required)
(Required)
2. ABA/BANK ROUTING NUMBER (Required)
3. DEPOSITOR ACCOUNT NUMBER (Required)
Memo _____[EXAMPLE]___________
_____________________
Location of account numbers are on bottom of your check:
123456789
2345678
9876
Routing number
Account number
Check #
4. FINANCIAL INSTITUTION NAME (Required)
5. NAME(S) AS THEY APPEAR ON ACCOUNT (Required)
6. FINANCIAL INSTITUTION ADDRESS (Required)
-
(Number and Street)
(City)
(State)
(Zip)
I have verified the account number above. This Financial Institution is ACH capable and will comply with NACHA rules.
(SFMS will accept Agency Payroll Office signature for State Employees travel reimbursements.)
7. Financial Representative’s Name (Printed
8. Signature of Financial Representative
9. Telephone Number
10. Date
or Typed - Required)
(Required)
(Required)
(Required)
SECTION D – FOR DAS/EGS/FBS/SFMS USE ONLY
1. Vendor No. and Mail Code
2. Pre-note Date
3. NACHA Format
4. Notes
PPD+
CCD+
https://www.oregon.gov/das/Financial/AcctgSys/Pages/ach.aspx
SFMS/ACH Forms
:
Form SFMS ACH-1 (Rev 10/22/20)
Department of Administrative Services
EGS FBS SFMS /
ACH Coordinator
155 Cottage Street NE U60
Salem, OR 97301-3963
General Instructions
I.
Complete sections A and B
II.
Have your Financial Institution complete and sign Section C.
III.
Mail the original completed form (no faxes or copies accepted) to address above.
IV.
Mark envelope CONFIDENTIAL
Specific Instructions
Section A
1. Mark 1 Check Box for Type of Action:
• New (Start) – New enrollment, or re-enrolling after a cancellation.
• Change – Adding to or changing any existing contact information. NOTE - Section C may be left blank if changing only the
email address, telephone number, or mailing address. Section C must be completed if changing banking information.
• Cancel – To stop direct deposit payments. Future payments will be mailed to the address you provide on this form.
2. Social Security Number (SSN) or Federal Employer’s Identification Number (FEIN) or State of Oregon Employee ID (OR#)
found on employee pay stub: Disclosure of your SSN is voluntary pursuant to 42 USC 405(c)(2)(C). However, since the State of
Oregon is required to file information returns with the Internal Revenue Service under certain conditions, if you choose not to
provide your social security number you may be ineligible for this service.
3. Name and Address: Since there is a small possibility that a payment may have to be mailed to you, an address must be provided.
For vendors and recipients, this is the mailing address where you receive payments against your invoices. For state employees,
the address may be your home or work address.
4. Phone Number: Please provide a daytime phone number where you may be reached during business hours in case there are any
challenges setting up this service or delivering a future payment to you.
5. Email Address: Provide an email address to receive payment notification, and other pertinent information as needed. You will be
https://pmtinfo.dasapp.oregon.gov/.
provided a UserID in order to view itemized payment detail on the State’s website;
Section B
Read and sign the form to indicate your agreement with the terms and conditions specified on it. Only original signatures will be accepted.
Recovery of funds deposited in error. In the event that an erroneous EFT payment occurs, creating an over-payment, the State reserves the
right to debit (withdraw funds from) your account accordingly.
International transactions – In order to comply with the National Automated Clearing House Association (NACHA) Rules, the State is
required to determine if Direct Deposit funds from the State are moving entirely outside the U.S. If this is determined to be the case, the State
will not be able to remit funds electronically into your account.
Section C - Financial Institution must complete and sign this section (Bank, Credit Union, etc.)
For State employees travel reimbursements; SFMS will accept Agency Payroll Office signature.
1. Type of Account: Specify if Checking or Savings and if Personal or Commercial.
2. ABA/Bank Routing Number: This is always a nine-digit number. See the check numbering example below.
3. Depositor Account Number: This may have up to seventeen digits. See the example below.
Check Number: This may be located between the routing number and the account number or after. (Do not include)
If you have any questions, please contact us at:
ACH.Coordinator@oregon.gov
or
(971) 900-9771
Routing
Account
Check
Number
Number
Number
http://www.oregon.gov/DAS/Financial/AcctgSys/Pages/ach.aspx
Retain a copy for your records
Page of 2