NATIONAL AUTOMATED CLEARING HOUSE

ASSOCIATION (NACHA) REJECT FORM

Please be advised that we have received a notification from your bank that the bank account we are trying to deposit and withdraw
from is not accessible. To prevent the closure of your merchant account and get any funds on hold released please submit this form
along with the appropriate back up as described below.

IMPORTANT: Our Company ACH Identifiers for merchant account bank activity are WFBTS09305 and 1455324351. If your bank requires this
information to be on your account to accept debits and credits, please contact them to add these numbers prior to submitting this form to us
for processing.

MERCHANT INFORMATION VERIFICATION (REQUIRED) PLEASE PROVIDE 2 OF THE FOLLOWING

REQUESTOR'S LAST 4 OF TAX ID
NAME: DEBORAH SUE ANDERSON CURRENTLY ON FILE:

MERCHANT LAST 4 OF BANK ACCOUNT

PHONE NUMBER: 616 315 2304 NUMBER CURRENTLY ON FILE: 1423
MERCHANT DOING LAST 4 OF SSN:
BUSINESS AS: Layin Pipe Plumbing and Design 1386
MERCHANT ID NUMBER
(BEGINS WITH 9305): 930579840176180

SETTLEMENT INFORMATION:
NAME AND PHONE NUMBER ROUTING NUMBER BANK ACCOUNT NUMBER USE THIS ACCOUNT FOR:
OF FINANCIAL INSTITUTION: (SHOWN ON THE BOTTOM OF CHECK) (SHOWN ON THE BOTTOM OF CHECK) (SELECT ALL THAT APPLY)
✔ Daily Settlement
1. Fifth Third Bank Phone number 620 312 3549 041200050 7982665122 ✔ Monthly Billing
✔ Chargebacks
✔ Daily Settlement
Fifth Third Bank Phone number 620 312 3549 041200050 7982665122 Monthly Billing
2. ✔
✔ Chargebacks

WHEN BANK INFORMATION IS CHANGING:

Check
• Business name must match account on file.
• Starter checks will not be accepted (check number, routing
number and account number must be preprinted on the check.
Bank Letter
• Business name must match account on file. • Letter must be signed by an authorized bank official and
• Needs to be typed. include their printed name and phone number or a business
card must be affixed.
• Letter must be on bank letterhead with bank’s address & phone number.
• The authorized bank official signature is not required on the
• Letter must provide the full bank account number and full bank
form if the bank account information is changing.
routing number.

WHEN BANK INFORMATION IS STAYING THE SAME:

• No back up is required but an authorized bank official must sign the form and provide the requested information.

ACCOUNT REINSTATEMENT:
✔ By checking this box, you are agreeing to re-activate your account. You Once account is updated any held funds will be released to
acknowledge and agree that the terms, conditions and fees applicable your newly updated bank account within 5 business days.
the account at the time of account closure will also be reinstated.

CONTACT INFORMATION: IF YOU PROCESS DIRECTLY WITH ANY OF THE FOLLOWING COMPANIES,
PLEASE CONTACT THEM DIRECTLY TO MAKE THESE CHANGES:
Email: financialforms@cayan.com
Fax: 617-385-1135 American Express Ascentium Capital Leasing Discover Authorize.net
800-528-5200 855-727-1210 800-347-2000 877-447-3938
By signing below, you represent and warrant (i) that the information you have supplied is true and correct in all respects, and (ii) that you have the necessary
power and authority to execute and deliver this request and to take such action on behalf of the Merchant named above. You further acknowledge and agree that
TSYS is entitled to rely on the foregoing and that you will indemnify TSYS and its representatives for any violation or breach hereof.
Once account is updated any held funds will be released and any rejected fees owed to us for merchant services, gateway or Genius fees will be assessed against
your newly updated bank account within 5 business days. Going forward any funds owed for these services will also be debited from this account.

SIGNER OF THE ACCOUNT MUST SIGN AND DATE THE FORM; OTHERWISE THE REQUEST WILL BE DENIED.
DEBORAH SUE ANDERSON 09/20/2022
ACCOUNT SIGNER SIGNATURE ACCOUNT SIGNER PRINTED NAME DATE

BANK OFFICIAL SIGNATURE BANK OFFICIAL PRINTED NAME

BANK OFFICIAL TITLE BANK OFFICIAL PHONE NUMBER DATE

One Federal Street · 2nd Floor · Boston, MA 02110 · 800.941.6557

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