ASAP Payment Requestor Bank Information Form		
	Section I – Payment Requestor Organization Information		
										
	Payment Requestor Organization Name:	     		
										
	Address:	     		
										
	Primary Contact Name:	     		Phone:	     			
										
	Does your organization have multiple banking relationships?		If Yes, indicate if the information on the form is your first, second, third or 
  fourth banking relationship.   First     Second        Third          Fourth		
		  YES	  NO				
										
	If your organization is currently using ASAP, please indicate if this is an additional banking relationship or a change to your existing banking information.		
	 Add – effective date:	     		 Change – effective date:	     					
			
	Section II – Financial Institution Information		
	** The ABA, ACCOUNT NUMBER AND ACCOUNT TITLE must be accurate.  If there is any discrepancy, you will be required
     to submit a new ASAP Bank Information Form.  The form can be typed or handwritten, but not a combination of both.**		

	Bank Name:	Bank of America		
										
	Bank Mailing Address:	     		
										
	City, State, Zip:	     		
										
	ACH Account Information		
										
	Account Title:	Chief Financial Office of Florida     		ACH Coordinator’s Name:	     		
										
	Account Type:	   Demand		   Savings		ACH Coordinator’s Phone:	     			
										
	ABA Number:	 0    6    3    1    0    0     2    7   -   7_    	ACH Coordinator’s Fax:	     		
										
	Account Number (17 character maximum):	                                                                                  _    		
										
	Fedwire Account Information		
										
	Account Title:	Chief Financial Office of Florida		Fedwire Coordinator’s Name:	     		
										
				Fedwire Coordinator’s Phone Number:	     		
										
	ABA Number:	 0    2    6    0    0    9    5    9   -   3_   	Fedwire Coordinator’s Fax Number:	     		
			
	Section III – Approval By Financial Institution Official		
										
			     			
	Signature of Bank Official				Bank Official’s Title					
										
			     		     		
	Bank Official’s Name				Bank Official’s Phone Number			Date		
	Section IV – Approval by Financial Official		
										
			     		     		
	Signature			Name		Title				
										
	     		     		     		
	Organization Name			Phone Number		Date