Name

FEIN

Address

City State Zip

Telephone FAX

E-Mail for payment correspondence

Requested Method of Payment:

Account Type:

Bank Name

Branch (If applicable)

City State Zip

Transit/ABA # __ __ __ __ __ __ __ __ __ Account #

KHRC Internal Use:Program/Purchasing Approval ___________ __________ SAM.gov Finance Verification:

Date Initials

Finance Approval ___________ ___________Date Initials

Attach Voided Check Here

FOR ACH/EFT PAYMENTS ONLY:

** - DUNS # - Please provide if a DUNS # received from Dun & Bradstreet.

If the vendor selects ACH/EFT for their method of payment, the vendor authorizes Kansas Housing Resources Corporation (KHRC) to deposit payments into the checking or savings account at the financial institution named above. KHRC is authorized to initiate a correcting debit (withdrawal) if a credit is posted in error. This authority is to remain in full force and effect until KHRC has received written notification of its termination in such time and in such manner as to afford KHRC and the financial institution named a reasonable opportunity to act on it.

DUNS # **

Vendor Information

Check Credit card

ACH/ EFT *** (Preferred Method). Please complete ACH/EFT Payments section below and attach a voided check.

New Vendor

Checking Savings

SAM.gov verified (documentation attached)

Change of Address Change of Banking Information

SAM.gov N/A (credit card vendor)

General Ledger Loan

Revised 02/19/2020

785-217-2001 | KSHOUSINGCORP.ORG | 611 S. KANSAS AVENUE, SUITE 300 | TOPEKA, KANSAS 66603

***In order to strengthen internal controls, ensure prompt payment of funds and eliminate the risk of checks being lost in the mailing process, we will administer payments through ACH whenever possible.