Bill Code Action Request Form

The completed form should be sent via email to Billing Services Support at dit.incidents@nc.gov. If you have any questions, contact the DIT Customer Service Center at (919) 754-6000 or toll free at 1-800-722-3946.
(Please allow 7 days for processing.)

Action Request (Check the appropriate box)

ADD 		To Request a new Bill Code (a new code will be assigned by DIT)

UPDATE 		To Correct errors or make changes to specific items of an existing Bill Code
(specify your assigned three-character code in the Bill Code field)

Dept Code	Bill Code

DELETE 		To Terminate an existing account code (specify your assigned three-character code in the Bill Code field)
Note: A separate Remedy ticket must be submitted to each Service Provider (i.e., Email, Desktop, Batch jobs, etc.)
utilizing this bill code to ensure service charges are discontinued.

Customer Information (Provide your business Federal Tax Identification Number and Business or Agency Name.)
[ For DIT Use Only ]

Federal Tax ID 	Agency or Business Name 	Customer Type
(Federal, Local, State, Private)

Agency Service Information (Specify the title of the application, project, department or other purpose for this request.)

Description of Service	Mainframe Access (Y or N)
(Circle One)

Accounting Distribution (Specify the budget code in your chart of accounts from which invoices will be paid by your organization.)

Notes: 	(1) Enter the budget code in the format according to the type of accounting system used by your organization.
(2) This information will appear on the invoice you receive from DIT and is for informational purposes only.

Fiscal Office Information (Provide the contact information of your Financial Office and the email address where the invoice will be sent.)

Fiscal Officer Name & Title

Last

First

Title

Email Address

Phone Number

Fiscal Office Mailing Address

Address 1

Address 2

City

State

Zip Code

Responsible Person (Provide the contact information of the person in your organization responsible for managing Bill Codes.)

Responsible for Application

Last	First	Title

Email Address

Agency Certification (Certification is mandatory. The Fiscal Officer's signature is required.)

Fiscal Officer 	Date: Responsible Person 	Date:

Invoices are due and payable in full upon receipt.

DIT reserves the right to revoke access if billing and access conditions are violated.

Phone Number