Revised March 2020
COMPANY/INDIVIDUAL ELECTRONIC PAYMENT INFORMATION
(For United States Banks Only)
COMPANY/INDIVIDUAL INFORMATION
Company/Individual
Name
(as appears on bank account )
Tax ID (EIN):
(as it appears on W9)
Address
Street
City
State
Zip Code
EFT/EDI Contact
Name(s)
A/R Contact
Telephone #
Name(s)
Fax #
A/R Contact E-mail
Email address to submit
remittance information.
US ACH BANK INFORMATION (Your local branch contact)
Bank Name
Address
Street
City
State
Zip Code
Bank Contact
Name(s)
Telephone #
Fax #
ACH Routing #
Note: This may be different than a fed wire routing number.
Bank Account #
Account Type
Checking
Savings (not currently available)
I hereby authorize initiation of direct deposits of accounts payable disbursements from Vanderbilt University
Medical Center into the account specified above and agree to promptly return any funds that are submitted in
error.
Signature: ________________________________________________
Print Name: ________________________________________________
Title: ________________________________________________
## Please note that a CTX 820 remittance file is forwarded to the receiving bank for each ACH payment. An
optional email remittance report is available upon request for those who do not retrieve the CTX 820
remittance detail file from their bank. Currently, this report is generated daily even though a payment may
not have been processed. Please return this form to VUMC Disbursement Services at
vumcdspaymen[email protected] or submit any questions you may have.
