New CRA Disaster Assistance Grant Program Vendor ACH Form

As an award recipient for the CRA disaster assistance grant program, you must be setup as a City of Tallahassee Vendor in order to receive the grant via ACH.

Important: Even if your organization is an existing City of Tallahassee Vendor, it is necessary for you to complete the form. You must also enter the Unique Reference Number on this form that was sent to you with your award letter.

New CRA Disaster Assistance Grant Program Vendor ACH Form (required fields have a red asterisk)

* Reference Number (provided in your award letter):

* Entity Name 1:

Entity Name 2:

* Entity Address 1:

Entity Address 2:

* City:

* State (2-Letter Abbreviation):

* Zip Code:

* Business Contact Name:

* Business Contact Phone Number:

* Business Contact Email Address:

* Taxpayer Identification Number Type:
FEISSN

* Taxpayer Identification Number (Do not include dashes. Enter numbers only.):

* Bank Name:

* Bank Routing Number:

* Bank Account Number:

* Signature (click "Save Signature" when done signing)

By signing my full name, I am certifying that the number shown on this form is my correct taxpayer identification number and that all information contained is correct to the best of my knowledge.

* Print Name and Title:

Version: 3539 (7/1/2020 8:27 AM) |