THIS FORM MUST BE SIGNED AND DATED BY PAYEE.
Signature below signifies acceptance of the terms and conditions in the AGREEMENT.
Under penalties of perjury, I certify that:
- The number shown on this form is my correct taxpayer identification number and
- I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
- I am a U.S. citizen or other U.S. person.
- My Organization represents and warrants it has checked the U.S. General Service Administration's (GSA) Excluded Party Listing System (EPLS). The University will terminate any contract without penalty to the university if my organization becomes excluded during the life of any contract.
- I certify that the information contained herein is correct. I understand that misrepresentation may be cause for removal from the qualified vendor list and any other penalties allowed by Law.
- The vendor must complete a new form if any vendor information in this form changes.
I hereby authorize and request Delaware State University to initiate credit entries and, if necessary, a debit entry in accordance with NACHA rules reversing a credit entry made in error, to my account at the financial institution named. The electronic payment data remains in effect until withdrawn by:(a) Written notification to the University; (b) Death or legal incapacity;(c) The financial institution or(d) Delaware State University.
Next Steps to Payment
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