Free 53788.pdf - Indiana

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Vendor Information
State Form 53788 (12-08) Approved by Auditor of State, 2008 Approved by State Board of Accounts, 2008

Name and telephone number of the Person who completed this document must be provided. Name: Daytime Telephone Number:

Send completed form to Auditor of State, 240 Statehouse, 200 W. Washington St., Indianapolis, IN 46204 or fax to (317) 234-1916
Print or Type

Legal Name (OWNER OF THE EIN OR SSN AS NAME APPEARS ON YOUR TAX RETURN. DO NOT ENTER THE BUSINESS NAME OF A SOLE PROPRIETORSHIP ON THIS LINE.) Trade Name (Doing Business as Name D/B/A) (Complete only if payment is to be made payable to the DBA name) Remit Address Purchase Order Address - Optional Enter 9-digit Taxpayer Identification Number (TIN) of the legal name:
(SSN=Social Security Number, EIN=Employer Identification Number)

(Individual's SSN) __ __ __ - __ __ - __ __ __ __

or

EIN __ __ - __ __ __ __ __ __ __

Check legal entity type (A box must be checked in this section. Check only one box.)

Individual Sole Proprietorship Partnership Estate / Trust Note: Show above, the name and number of the legal trust, or estate, not personal representatives Other [Limited Liability Company (LLC) (attach IRS Form 8832 if applicable), Joint Venture, Club, etc.] Corporation Do you provide legal or medical services? Yes No Government (or Government operated entity) Organization Exempt from Tax under Section 501(a)
One box must be checked
Add Deposit SECTION 1: AUTHORIZATION According to Indiana law, your signature below authorizes the transfer of electronic funds under the following terms: Account Holder's Name: Type of Account: Checking (Demand) Savings Account Number: I am a U.S. Person (including a U.S. resident alien) I am not a U.S. Person (a W-8 must be filed with the Auditor of State) Change Deposit Indiana law (I.C. 4-13-2-14.8) requires that YOU receive PAYMENT(S) by means of electronic transfer of funds.

SECTION 2: FINANCIAL INSTITUTION'S APPROVAL (Attach a voided check or have your financial institution complete this section) The financial institution identified below agrees to accept automated deposits under the terms set forth herein: Name of Financial Institution: ___________________________________________________________________________________________________ Telephone: ( Address: Number and Street, and/or P.O. Box No. City, State, and Zip Code (00000-0000) ABA Transit-Routing Number Date Financial Institution's Authorized Signature Title , 20 )___________________________________________

ATTACH VOIDED CHECK HERE

SECTION 3: ELECTRONIC NOTIFICATION OF ELECTRONIC FUND TRANSFER (EFT) DEPOSITS
(Complete this section only if you are requesting electronic notification. You may provide up to four email addresses.)

I hereby request that all future notices of EFT deposits to the bank account specified above be sent to the following email addresses:

I agree to the provisions contained on the reverse side of this form. NAME (Print or Type) AUTHORIZED SIGNATURE DATE TITLE PHONE

ATTACH VOIDED CHECK HERE

REQUEST FOR VENDOR INFORMATION
THIS FORM APPLIES TO YOU, IF YOU ARE: 1) 2) 3) A U.S. person (including a U.S. resident alien); and A person, business, or other entity who has or will receive a payment from the state; or A state employee who has or will receive a payment, other than payroll, from the state.

PURPOSE OF FORM: The Auditor of State of Indiana (Auditor) must have correct vendor information to make payments to vendors. This includes the vendor's legal name, doing business as name (if any), address, Taxpayer Identification Number (TIN), entity type, and banking information. This form allows you to provide your correct name, address, TIN, entity type, and banking information. If you do not provide us with the information, your payments may be subject to federal income tax withholding. In addition, if you do not provide us with this information, you may be subject to a penalty imposed by the Internal Revenue Service per I.R.C. 6723. Federal law on withholding preempts any state and local law remedies, such as any rights to a mechanic's lien. If you do not furnish a valid TIN, we are required to withhold a percentage of our payment to you. Withholding is not a failure to pay you. It is an advance tax payment. You should report all withholdings as a credit for taxes paid on your federal income tax return. INSTRUCTIONS: 1) Enter your legal name on the designated line. Your legal name is the one that appears on your Social Security Card or, if you are a business, the Employer Identification Number (EIN) as it is in the IRS records. If you are a sole proprietor, then your legal name is the business owner's name. If you have a "doing business as" (d/b/a) name, enter this on the trade name line. Enter your remit address on the next line, and if you have a separate address for purchase orders, enter that address on the appropriate line. Record the appropriate TIN in the space provided and check the box that corresponds to the correct organization type for your name. Note that individuals and sole proprietors are the only types that should record a social security number (SSN). a) If you are a corporation, you must indicate whether you provide legal or medical services. b) If you are a sole proprietor, you must show the business owner's name in the legal name box and you may show the business name in the trade name box. You cannot use only the business name. For a sole proprietor, you may use either the individual's SSN or the EIN of the business. However, we prefer you provide the SSN. Check the appropriate box that indicates whether you are or are not a U.S. person. Complete Section 1: Authorization Have your financial institution complete Section 2: Financial Institution's Approval. Your financial institution should return the completed form to you. A voided check may be provided in lieu of having your financial institution complete this section. Deposit slips will not be accepted. Complete Section 3: Electronic Notification of Electronic Fund Transfer (EFT) Deposits, only if you choose to receive electronic EFT notifications by email. If this section is not completed, your notification will be sent by U.S. Mail to the remit address designated on the reverse side of this form. Fax the completed form to (317) 234-1916 or mail to the Indiana Auditor of State, 240 Statehouse, 200 W. Washington St., Indianapolis, IN 46204. Retain a copy of the completed form for your records. Any form submitted without an authorized signature will be destroyed and will not be entered into the Auditor's vendor file.

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3) 4) 5) 6) 7) 8) 9)

BY SIGNING THIS FORM: You represent that you understand and agree that: 1) You are authorized to provide this information on behalf of yourself or your organization. 2) The State of Indiana is authorized to initiate credits (deposits) in various amounts, by EFT through automated clearing house (ACH) processes, to the checking (demand) or savings account in the financial institution designated on the reverse side of this form. 3) If necessary, you will accept reversals from the State for any credit entries made in error to a bank account per National Automated Clearing House Association (NACHA) regulations. 4) You may only revoke this request and authorization by notifying the Auditor in writing, at the above address, at least fifteen (15) days before the effective date of revocation. 5) Any change to the account or to a new financial institution will require a new Vendor Information form be completed and submitted to the Auditor of State at the above address. Failure to provide timely notification to the Auditor that your account has changed will result in a delay in payment. 6) The State of Indiana and its entities are not liable for late payment penalties or interest if you fail to provide information necessary for an EFT transaction and/or you do not properly follow the Instructions above. 7) The email addresses provided in Section 3 for electronic EFT notification will allow for appropriate application of all payments. 8) You acknowledge that it will cause disruption to the notification process if the email addresses provided for electronic EFT notification are frequently changed or changed without promptly providing an updated email address to the Auditor. 9) You acknowledge that an email notification returned as undeliverable may be removed from the Auditor's email notification system and all future notices of EFT deposits to you will be provided by the Auditor via U.S. Mail to the remit address designated on the reverse side of this form until you have provided a valid email address to the Auditor. 10) You are responsible for contacting the Auditor if you are not receiving electronic notices of EFT deposits.