NJ ACH REVISED 07/24
Electronic Payment Authorization Instructions for Non-Procurement Vendors
The electronic payment authorization form is required for non-procurement vendors/payees that elect to have their
payments disbursed electronically via the automated clearing house (ACH) program. Procurement vendors SHOULD
NOT complete this form but should register at NJSTART.GOV. Procurement vendors include vendors who sell goods or
provide a service (including healthcare and legal services).
Once completed, the signed electronic payment authorization form must be submitted with either a voided check OR
bank issued account verification letter. The bank letter must include ABA number (routing or transit number), bank
account number, and type of account (checking or savings).
PLEASE CLEARLY TYPE OR PRINT AL
L ENTRIES
Select the appropriate action requested. For payees electing to participate in the ACH program for the first time, select
‘Establish New ACH.’ For existing ACH payees that are requesting a bank account change, select ‘Change/update bank
information.’ For payees that desire multiple bank accounts be added to their payee record, select ‘Establish new
location code’ and indicate the title of the account.
1. Name: Enter the vendor/payee receiving the automatic deposit transaction. The name must not exceed 30
positions including spaces and punctuation marks. Abbreviate as required to stay within the 30 position limit.
2. Bank Name: Enter the name of depository bank/financial institution receiving ACH credit.
3. Account Type: Check appropriate box.
4. Authorized Agents' Date, Signatures & Title: A minimum of two signatures is required when payment will be made
to a corporation, partnership, or joint account. For a vendor, the "Agent" signature must include an office manager,
supervisor, or individual responsible for the depository process. Only one signature is required for Sole Proprietors.
5. Telephone No(s): Enter telephone number, including area code.
6. Vendor No: Enter the nine-digit vendor number assigned by the State of New Jersey. (This often equals a
social security number for non-State employees and Federal ID number for vendors.) Leave
the two position field
following the vendor number blank if unknown.
7. Bank Transit/ABA No: Enter bank’s nine-digit American Banking Association Number. This number is also known as
the bank transit or routing number.
8. Account No: Enter checking/savings account number. This is a variable length field; the size is dependent on the
receiving bank's account structure.
NOTES:
When a change is made to the payees' ABA and/or account number, the payee is required to notify the State as soon as
possible to allow time for the preparation of a new authorization form and to allow for the pre-notification of
the changes to the State’s disbursing bank.
Details regarding specific payments, similar to a check stub, may be obtained over the internet through the Vendor
Payment Inquiry (VPI) system. To access VPI, users must first create a ‘MyNewJersey’ portal account. Begin by logging
onto the State of New Jersey’s web page, NJ.GOV and creating a log in and password (click on the ‘Sign Up’ link under
the ‘Login’ tab). Once the ‘MyNewJersey’ portal account has been established, users will have to sign up for the VPI
application by clicking the ‘enroll here’ button on our website, https://www-tyomb.nj.gov/TYM_VPI/home. The online
tutorial for VPI can be found at https://www-tyomb.nj.gov/treasury/omb/TYM_VPI/docs/GettingStarted.pdf. VPI
provides two years of historical data (such as issuing agency, payee reference, payment amount, payment date, etc) and
allows for the review of scheduled payments.
Form Distribution: The completed form, along with the required voided check or bank issued account verification letter,
should be mailed or emailed to:
OMB-Vendor Control
PO Box 221
Trenton, N.J. 08625-0221
Email: [email protected]
NJ ACH REVISED 07/24
Electronic Payment Authorization
For Non-Procurement Vendors
New Jersey Department of the Treasury
I (we) hereby authorize the New Jersey Department of the Treasury to initiate
electronic (ACH) CREDIT entries into the bank account named below. This authority is
to remain in full force and effect until the New Jersey Department of the Treasury has
received written notification of any changes, and in such manner as to afford the New
Jersey Department of the Treasury a reasonable opportunity to act.
Action Requested:
Establish new ACH (first time users)
Change/Update bank information
Establish new location code (indicate type
i.e.
cafeteria plan, EDRS,
etc.):
NAME:
BANK NAME:
(30 positions max)
ACCOUNT TYPE: Savings Checking
AUTHORIZED AGENT: (a minimum of two signatures unless individual or sole proprietor)
Date:
/
/
Signed:
Title:
Date:
/
/
Signed:
Title:
Telephone Number (
) Telephone Number (
)
Please attach a voided check or bank letter to the form in confirmation of the above
account.
Enter the specified three numbers below:
Vendor Number
Bank Transit Number
Account Number
Ent
er “X” if the financial institution receiving your payment is a foreign bank or is acting as an agent
for a foreign bank on your behalf.
Details regarding specific ACH payments, similar to a check stub, may be obtained over the
internet through the Vendor Payment Inquiry (VPI) system. VPI also provides two years of
historical data and allows for the review of scheduled payments. See Electronic Payment
Authorization Instructions on how to obtain an authentication code to access VPI.
