ELECTRONIC TRANSFER OF FUNDS AUTHORIZATION
Georgia Online Database (GOLD) Reimbursement Payments

ACH / Fund Transfer Program Details

Provision of the information required below is necessary to support the electronic transfer of funds directly to a member library’s institutional account. All data submitted will be formatted in tables and provided directly to:

Board of Regents University System of Georgia
Nancy Tupper
Accounts Payable Department
270 Washington Street, S.W.
Atlanta, Georgia 30334
Phone: (404) 657-1829
Fax: (404) 657-5977
E-mail: Nancy.Tupper@usg.edu

All fields must be complete for the form to be submitted

Institution & Library Name:
Federal Employer ID #

An FEIN is usually written in the form 00-0000000

A Federal Employer Identification Number (FEIN) or the Federal Tax Identification Number is a unique nine-digit number that the IRS assigns to business entities operating in the United States for purposes of identification. FEINs are used by employers, sole proprietors, corporations, partnerships, non-profit organizations including libraries, trusts and estates, government partnerships, certain individuals and other business entities.

Bank or Financial Institution
where Library Account is Held

Bank Name:

City:

State:

Routing Number
Account Number
Financial Contact Person

Name:

Position Title:

E-Mail:

GOLD Library Contact Person

Name:

Position Title:

E-Mail:

Authorization

I authorize the Board of Regents and the Financial Institution listed to deposit my (or my company/corporation’s) net payment automatically to my (or my company/corporation’s) account each time a payment is due me (or my company/corporation’s). This authority will remain in effect until I (or my company/corporation’s) cancel in writing.


All fields must be complete for the form to be submitted