FIDF - Domestic Vendor Payment Request

Complete all fields clearly. For new vendors, include Tax ID for a business or SSN for an individual, along with a W-9.

Pay To

New Vendor

Address

Tax ID (Business) or SSN (Individual)

Required for new vendors.

Select payment method:

ACH Wire Transfer Check Zelle

Bank Name

Account Holder Name

Routing Number (ABA)

Account Number

Account Type

Bank Name

Account Holder Name

Routing Number (ABA)

Account Number

SWIFT / BIC (if applicable)

Bank Address

Mail Check To (if different from address above)

Zelle Email or Phone Number

Registered Name on Zelle Account

Purpose of Payment

Invoice Reference

Preferred Email for Remittance Advice

Attachments Checklist:

Invoice

FOR INTERNAL USE ONLY - FIDF BACK OFFICE

#	Description	Region	Function / Event or Adm.	Account	Amount

Total

Requested By Signature Date

Approved By Signature Date