Authorization & Payment Set-Up Form

SCRIP VENDOR AUTHORIZATION & PAYMENT SET-UP FORM

To be completed by the Scrip Vendor Page One

1. Scrip Vendor Name: 2. Remit to Address (line 1): Remit to Address (line 2): City: State/Province: Zip / Postal Code: 3. Contact Name: Contact Phone #: 4. E-mail address for payment notification: 5. Taxpayer ID #:

Payment will be sent to your bank electronically using the ACH (Automated Clearing House) funds transfer format. Please complete the following information to set up electronic payments. If you have any questions regarding ACH transfers, please contact Raley’s Accounts Payable at (916) 373-6401.

6. Bank Name: 7. Address 1: Address 2: City: State/Province: Zip / Postal Code: 8. Bank Contact Name: Phone #: 9. Bank Fax # for Verification of Account Information:

10. Bank ABA/Routing/SWIFT #:

10. Bank Account #: 11. Attach a voided check or deposit slip.

13. My signature below authorizes our bank representative to verify our account information to Raley’s. I certify the above to be true and correct to the best of my knowledge.

By: Signature of Scrip Vendor Representative (original signature required)

14. Name Title Date

15. SCRIP VENDOR: Attach a copy of a check or deposit slip for your organization or company and return this form to Raley’s Accounts Payable, P O Box 15618, Sacramento, CA. 95852. SCRIP VENDOR AUTHORIZATION & PAYMENT SET-UP FORM

To be completed by Raley’s Page Two SCRIP VENDOR NAME:

Accounts Payable will complete this section:

1. New Vendor Change Existing Vendor

7. Approved By: Signature

8. Printed Name OPX # Date

Financial Services will complete this section:

Bank Info Verified: Date: Type of verification: Pre-note Bank Personnel (write name & contact info below)

Update ACH Matching Database: Data entered by Laura  Date:

Data reviewed & approved by Troy  Date:

VENDOR #:

A/P Trading Partner set up in PeopleSoft by J. Hannibal:  Date:

A/P Trading Partner changed to ACH (remove hold if necessary)  Date: