Electronic Fund Transfer (EFT) Authorization Form

Complete the items below and click Submit to confirm submission.

Please note: Partially completed information cannot be saved, be sure to have all details with you before beginning the form. For the best form completion experience, use the Google Chrome browser.

* Required Field

Select the Request Type

First Time EFT Enrollment

Modify Existing EFT Information

NYSERDA assigned Supplier Identification Number

Current Legal Business Name

DBA name you have with NYSERDA (if applicable)

Federal Employer Identification Number (FEIN/TIN)

Bank Name already on file with NYSERDA

(applicable only to Requests for Modification of EFT information)

Bank’s Routing Number already on file with NYSERDA (see example below)

(applicable only to Requests for Modification of EFT information)

Bank Account Number already on file with NYSERDA (see example below)

(applicable only to Requests for Modification of EFT information)

[New] Bank Name for all future payments from NYSERDA

(applicable to First Time Enrollment AND Modification request types)

[New] Bank’s Routing Number for all future payments from NYSERDA (see example below)

(applicable to First Time Enrollment AND Modification request types)

[New] Bank Account Number for all future payments from NYSERDA (see example below)

(applicable to First Time Enrollment AND Modification request types)

NOTE: A CALLBACK WILL BE MADE TO CONFIRM THIS REQUEST

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

Payment Notification Email 1

Payment Notification Email 2

Phone Number (including area code)

Authorized Official Signature

First Name

Last Name

Choose how to sign

Draw Type

I certify, agree, and acknowledge that I have read and understand this Electronic Fund Transfer (EFT) Authorization Form, for the New York State Energy Research and Development Authority (NYSERDA) to deposit funds into the newly designated bank account through an EFT. I understand that EFT payments are not deemed to have been made until the date on which the applicable amount has been transferred into my organization’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 completed, NYSERDA may use any other lawful means to recapture payments for which I was not entitled. The Agreement represented by this authorization remains in effect until written notification or cancellation is provided by this organization. I certify under the penalties of law that I have examined the information I have provided on this form and that the information I provided is true, accurate, and complete and that I have the authority to sign on behalf of the organization named on the Form. I understand that by signing this form, I consent to any other inquiry, a phone call to me or a phone call to a second person within this organization to verify or confirm the information I have given. I further certify, agree, and acknowledge that the organization will indemnify, defend, and hold harmless NYSERDA and the employees, officers, directors, and agents of NYSERDA from and against any and all losses, claims, demands, actions, liabilities, damages, fines, penalties, levies, costs, expenses, charges, and attorneys’ fees and disbursements (including in enforcing this indemnity) arising from, in connection with, related to, and/or resulting from any payment through an EFT or otherwise, any fraud, and/or any misrepresentation.

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