EFT Bank Information and Authorization Form

PLEASE COMPLETE THE ITEMS BELOW AND CLICK THE SUBMIT BUTTON ON THE BOTTOM OF THIS FORM WHEN COMPLETE

* Required Field

Federal Employer Identification Number (FEIN)

Legal Business Name

Supplier Identification Number

Financial Institution

Routing Number (see example below)

Account Number (see example below)

NOTE: A CALLBACK WILL BE MADE TO CONFIRM THIS REQUEST

Authorized Official Signature Here

First Name

Last Name

Choose how to sign

Draw Type

I certify that I have read and I understand this Electronic Payments authorization, for New York State Energy Research and Development Authority (NYSERDA) to deposit funds into the designated bank account through an electronic fund transfer (EFT). EFT Payments are not deemed to have been made until the date on which the applicable full invoice amount has been transferred into the payee’s account. In the event that an erroneous electronic payment is sent, NYSERDA reserves the right to 'reverse' the electronic payment. In the event that 'reversal' cannot be implemented, NYSERDA will utilize any other lawful means to retrieve payments to which the payee was not entitled. The Agreement represented by this authorization remains in effect until written notification of cancellation is provided by the payee.

Please provide at least one email address to receive payment notifications from NYSERDA

Payment Notification Email 1

Payment Notification Email 2

Phone Number