Attachment_10_-_ACH_Payment_Enrollment_Form.pdf

Original Attachment #10, Solicitation 2014-N-16601

Attachment 10

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. Recipients of these payments should bring this information to the attention of their financial institution when presenting this form for completion. See reverse for additional instructions.

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 through the Automated Clearing House Payment System.

AGENCY INFORMATION

FEDERAL PROGRAM AGENCY

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Procurement and Grants

Office

AGENCY IDENTIFIER:

AGENCY LOCATION CODE (ALC):

ACH FORMAT

CCD + CTX CTP

ADDRESS:

2920 Brandywine Road, M/S K-75

Atlanta, GA 30341

CONTACT PERSON NAME:

Patrick Gourley

TELEPHONE NUMBER:

(770) 488-2825

ADDITIONAL INFORMATION:

Award Number: 200-

PAYEE/COMPANY INFORMATION

NAME

SSN NO. OR TAXPAYER ID NO.

ADDRESS

CONTACT PERSON NAME:

FINANCIAL INSTITUTION INFORMATION

NAME:

ADDRESS:

ACH COORDINATOR NAME:

NINE-DIGIT ROUTING TRANSIT NUMBER:

DEPOSITOR ACCOUNT TITLE:

DEPOSITOR ACCOUNT NUMBER:

LOCKBOX NUMBER:

TYPE OF ACCOUNT:

CHECKING SAVINGS LOCKBOX

SIGNATURE AND TITLE OF AUTHORIZED OFFICIAL:

(Could be the same as ACH Coordinator)

AUTHORIZED FOR LOCAL REPRODUCTION SF 3881# (Rev 2/2003) Prescribed by Department of Treasury

31 U S C 3322; 31 CFR 210

Instructions for Completing SF 3881 Form

1. Agency Information Section - Federal agency prints or types the name and address of the Federal program agency originating the vendor/miscellaneous payment, agency identifier, agency location code, contact person name and telephone number of the agency. Also, the appropriate box for ACH format is checked.

2. Payee/Company Information Section - Payee prints or types the name of the payee/company and address that will receive ACH vendor/miscellaneous payments, social security or taxpayer ID number, and contact person name and telephone number of the payee/company. Payee also verifies depositor account number, account title, and type of account entered by your financial institution in the Financial Institution

Information Section.

3. Financial Institution Information Section - Financial institution prints or types s financial institution who will the name and address of the payee/company receive the ACH payment, ACH coordinator name and telephone number, nine-digit routing transit number, depositor (payee/company) account title and account number. Also, the box for type of account is checked, and the signature, title, and telephone number of the appropriate financial institution official are included.

Burden Estimate Statement

The estimated average burden associated with this collection of information is 15 minutes per respondent or record keeper, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Financial Management Service, Facilities

Management Division, Property and Supply Branch, Room B-101, 3700 East West Highway, Hyattsville, MD

20782 and the Office of Management and Budget, Paperwork Reduction Project (1510-0056), Washington, DC

20503.