Well Managed

ACH – Direct Deposit Enrollment Form

Riverbend Energy Group is now offering owners/vendors the option to electronically deposit their revenue checks via ACH – Direct Deposit. If you are interested in choosing this method of payment, please fill out the following form, along with a completed W-9 and a copy of a voided check or ACH Statement.

Step 1: Enrollment

Enrollment

New Change Cancel

Email address

We'll never share your email with anyone else.

Note: You will need to confirm your e-mail address after submitting.

Phone Number

We'll never share your contact with anyone else.

Owner/Vendor Name

Please provide the legal name associated.

SSN/TIN #

W-9 must be attached.

Owner Number

If known.

Type of Account

Checking Savings

Account Number

Routing Number

Must be 9 digits.

Bank Name

Bank City/State/Zip

Step 2: Address Change

Check box to change the address currently on file with Riverbend to the one listed above.

Mailing Address

City/State/Zip

Step 3: REQUIRED DOCUMENTATION

1- Please provide a voided check or ACH Statement from your bank.

2- Please provide a completed W-9 Form for verification purposes.

Failure to provide the required documentation will result in the delay of your ACH enrollment/change.

Step 4: SIGNATURES

By signing below, I hereby authorize Riverbend Energy Group, its affiliates, and my financial institution to electronically deposit my payment to the account specified. Further, I agree not to hold Riverbend Energy Group and its affiliates responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or my financial institution or due to an error on the part of my financial institution in depositing funds to my account. I understand that I can change my account or financial institution instructions at any time by completing a new Direct Deposit form. If this is a joint account, both owners must provide a signature below.