ACH Form.pdf

CDC FMO

REVISED 01/29/04

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 U.S.C. 3322 and 31 CFR 210. This information will be used by the Treasury Department to transmit payment data, by electronic means to vendor's financial institution. Failure to provide the requested information may delay or prevent the receipt of payments.

ACH VENDOR/MISCELLANEOUS PAYMENT

ENROLLMENT FORM

This form is used for Automated Clearing House (ACH) payments with an addendum record that contains payment-related information processed through the Vendor Express Program.

AGENCY INFORMATION

FEDERAL PROGRAM AGENCY

AGENCY IDENTIFIER: AGENCY LOCATION CODE (ALC): ACH FORMAT:

CCD+ CTX CTP

ADDRESS

CONTACT PERSON NAME: TELEPHONE NUMBER:

ADDITIONAL INFORMATION

PAYEE/COMPANY INFORMATION

PAYEE/COMPANY NAME: SSN NO. OR TAXPAYER ID NO.

ADDRESS: DUNS+4 NUMBER

CITY STATE ZIP

CONTACT PERSON NAME: TELEPHONE NUMBER:

FINANCIAL INSTITUTION INFORMATION

FINANCIAL INSTITUTION NAME:

ADDRESS ( OR BRANCH):

CITY: STATE: ZIP:

NINE-DIGIT ROUTING TRANSIT NUMBER:

DEPOSITOR ACCOUNT NUMBER:

TYPE OF ACCOUNT:

CHECKING SAVINGS

ACH COORDINATOR NAME OR AUTHORIZED OFFICIAL AT FINANCIAL INSTITUTION ( NOT REQUIRED): TELEPHONE NUMBER:

CDC 0.4433 (E), Rev. 2/2003, CDC Adobe Acrobat 5.0 Electronic Version, 8/2004