Bank Account Information Form General Bank Information Section Agency Name Agenc

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Bank Account Information Form General Bank Information Section Agency Name Agenc Powered By Docstoc
					                                                      Bank Account Information Form
                                                  General Bank Information Section
     Agency Name:

     Agency Number:

     Agency Contact Person:

     Agency Contact Phone Number:

     Agency Address:


     Bank Name:

     Bank Contact Person:

     Bank Contact Phone Number:

     Address:

     Address:

     City/State:

     Zip Code:

     Routing (DFI or ABA) Number:


     Fill out appropriate sections below.
     Please attach a bank "specification sheet for printing MICR documents" for each account listed below.

                                                             AP/AR Section

     For what Function is this bank account used:
     Accounts Payable and Accounts Receivable. Please complete all questions.
     Accounts Payable ONLY. Please complete all questions.
     Accounts Receivable ONLY. Please complete questions #1-4.

1    What is the bank account number?
     What type of account is it? (Operating, Fiduciary,
2    Revenue Collections, etc)

3    What is the Bank Location:

     What SCOA account number is used for this bank
     account? (Refer to the Audit Department-Listing of
4    Summary Accounts, i.e. 101001)

5    What type of reconciliation do you plan to do?               Manual                     Automatic
6    Do you plan on using positive pay?

     How should the Bank Account number appear on the
7    check? Please indicate any spaces with an X.

8    How should the Bank Name appear on the checks?

9    How should the Bank Address appear on the checks?
     What is the Fractional Routing number? (top right
10   corner of check)

11   Who is the primary person authorized to sign checks?

12   Is this signature on file with GTA?                          Yes                        No
       Indicate all types of payments that will be generated
       from this account. (System checks, EFT, Manual
13     checks, Wire Transfer)
       If System check is applicable, what is the beginning
14     system check number?
       If Manual check is applicable, identify beginning and
15     ending range of check numbers.

       For Financial Systems Use Only
       Bank Code:                                              Bank Location:         Bank Account Code:




                                                               Payroll Section

       Type of Transaction (choose one)
       Are you changing banks/new bank name?
       Are you choosing/discontinuing Direct Deposit?


1      What is the bank account number?

2      What SCOA will be used?


3      Who is the primary person authorized to sign checks?

4      Is this signature on file with GTA?                          Yes                    No

5      What Check number do you want to start with?
       How many system generated blank checks
6      requested?

7      What effective date is requested?

8      Will you offer Direct Deposit?                               Yes                    No

9      Will you be using bank reconciliation?                       Yes                    No
         OR
10     Will you be using positive pay?                              Yes                    No

     For payroll, please attach a copy of the signed Automated Clearing House (ACH) Service Agreement between agency and bank.


       Please send all information to:
         GTA Financial Systems
         200 Piedmont Avenue
         Suite 1604 W. Tower
         Atlanta, GA 30334
         Ph # 404 656-2133
         Fax # 404 463-5089

       For payroll e-mail gtahrms@gta.ga.gov
       For accounts payable e-mail acctspay@gta.ga.gov
       For accounts receivable only bank accounts e-mail finacctg@gta.ga.gov

				
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Description: Bank Account document sample