SPF Electronic Funds Transfer Form

Please contact us if you have any questions.

Justine Latiano, Accounting Director Justine@statepowerfund.org

Check One

New Vendor/Individual

Updated Information

I/We hereby authorize that all future payments be made via Electronic Funds Transfer as per the following bank details

Vendor Details

Individual/Organization Name

Email address

Address

Bank Information

Name on Bank Account

Bank Name

ACH Routing Number

*Found on Check, 9 digits

Account Number

I/We will be responsible for notifying State Power Fund in writing of any changes in the above particulars. Until receipt of such notifications, State Power Fund shall process all payments in accordance with the above particulars.
I/We warrant that the bank account details so provided are not false and comply with all applicable laws.
State Power Fund has the right to accept the authority of the undersigned as conclusive evidence of that persons authority to execute this agreement on behalf of the supplier. State Power Fund is under no obligation to verify the authority of the undersigned on the Bank Account details.
I/We acknowledge that it is not practicable for State Power Fund to keep banking details confidential, to the extent that these will be available to State Power Fund staff in carrying out their normal duties in paying creditor accounts.
State Power Fund will not be responsible for any delays in the payment or errors due to factors outside the reasonable control of State Power Fund (including but not limited to delays and errors in the banking system).
State Power Fund reserves the right at any time to terminate or suspend this direct credit payment method and to pay by check or any other manner which State Power Fund may determine.

Name of Authorized Individual

**The above named person has authority on the listed bank account to acknowledge the above statements and agree to them as of the date this form is submitted.

PERSONAL INFORMATION PROTECTION STATEMENT

Personal information we collect from you on this Electronic Funds Transfer Form will be used by State Power Fund and their staff for the purpose of making payments to you for grants, loans, invoices or other payments as may be necessary from time to time. Your personal information will be used for the primary purpose for which it is collected, and may be disclosed to contractors and agents of State Power Fund. Your basic personal information will only be disclosed to other public sector bodies where necessary for the efficient storage and use of the information.

Your information will be encrypted.

State Power Fund

Projects: Midwest Organizing Collaborative, State Revenue Alliance and We Make the Future -&- Fiscal Agents: Wisconsin RCN Education

Telephone 1 (844) 999-3755
www.statepowerfund.org
425 Cherry St, 2nd Floor, Kent, OH, 44240