CITY OF LOVELAND 
 
                                                                     FINANCE DEPARTMENT 
                                            Civic Center   500 East Third  Loveland, Colorado 80537 
                                    (970) 962-2308   FAX (970) 962-2994   TDD (970) 962-2620                                

                 ACH/EFT VENDOR ENROLLMENT FORM 
                                                       
                                            AGENCY INFORMATION 
Name:                   City of Loveland 
Address:                500 East 3  Street, Ste.rd320 

City/State/Zip:         Loveland, CO 80537 
Contact Name:           Tamara Hansen 
Telephone #:            970-962-2307         
Email:                  Tamara.Hansen@cityofloveland.org 
                                            COMPANY INFORMATION 
Name:                    
Address:                 
City/State/Zip:          
Contact Name:            
Title:                   
Signature:                                                                            Date: 
Telephone #:                                                                          Fax: 
Tax ID:                  
Email:                   
                            PAYMENT REMITTANCE INFORMATION 
Firm Name:               
Address:                 
City/State/Zip:          
Remit Contact:           
Title:                   
Signature:                                                                            Date: 
Telephone #:             
Fax #:                   
Email:                   
                            FINANCIAL INSTITUTION INFORMATION 
Bank Name:               
Address:                 
City/State/Zip:          
9-digit Routing Transit  
#: 
Account #:               
Type of Account:                      □  Checking                          □  Savings 
                                                       
By submitting this form to the City of Loveland (City), I authorize the City and the financial institution named above to 
automatically deposit funds I am entitled to receive into the account identified above (my account). I authorize the City to 
initiate correction (debit) entries for any funds credited to my account in error and authorize the financial institution to 
return any funds deposited to my account to the City. This authorization will remain in effect until I cancel it in writing. 
 
* If you are CHANGING BANKING Information:   
 
OLD (Current) Routing # _______________________________ 
 
OLD (Current) Acct # __________________________________