09-75A50126R00001_RFP Att 9 ACH Vendor Misc Payment Enrollment Form.docx
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- 75A50126R00001_RFP_NPIVS_27
About this file
This is an ACH Vendor/Miscellaneous Payment Enrollment Form template for electronic fund transfers related to federal contract payments.
The form is a standardized payment information document issued under the authority of 31 USC 3322 and 31 CFR 210, designed to facilitate payment transmission through the Automated Clearing House (ACH) system by the Treasury Department. It collects payee identification information (name, address, taxpayer identification number, and telephone number) and requires completion of banking details by an authorized financial institution representative, including the institution's name and address, nine-digit ABA routing number, depositor account title, account number, and account type (checking or savings). The form must be signed by both an authorized official of the financial institution and the payee to verify accuracy. This template is applicable to federal employees, offerors, and vendors receiving payments under federal contracts. Failure to complete and submit this form may delay or prevent payment receipt.
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Text version
ATTACHMENT #9
ACH VENDOR / MISCELLANEOUS PAYMENT ENROLLMENT FORM
Payment Information Form The information requested on this form concerns your financial institution, your account at that institution, and personal information which needs to verified and completed.
Privacy Act Statement The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). All information collected on this form is required under the provisions of 31 USC 3322 and 31 CFR 210. This information will be used by the Treasury Department to transmit payment data, by electronic means to your financial institution. Failure to provide the requested information may delay or prevent the receipt of payments through the Automated Clearing House Payment System.
Check one of the following:
Name: Federal Employee: Offeror: Vendor:
Business Address:
Remit To (If same as above, leave blank. Must match address on invoice for internal control purposes.) Address:
Taxpayer Identification # (TIN): (If you are an individual, this may be your Social Security number)
1. Payee's Telephone Number: ( ) The following information must be completed by your financial institution representative:
2. Name of Financial Institution:
3. Address of Financial Institution:
4. Financial Institution's 9-digit ABA Routing Number for Transfer of Funds: _ _ _ _ _ _ _
5. Depositor Account Title: _
6. Depositor Account Number:
7. Type of Account: Checking Savings
8. Signature and Title of Authorized Official of Financial Institution:
Telephone Number: ( ) Date: ____________ ************ The following must be signed by the payee**************
I have verified the information on this form.
| Signature |
| _ |
Date
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