RFP Attachment 8 ACH_Misc. Payment Enrollment Form.pdf
PDF 265 KB Posted
- Solicitation number
- 2021-44934
About this file
This document contains a pre-solicitation notice and form related to the Safe Healthcare, Epidemiology, and Prevention Research Development (SHEPheRD) Program contract opportunity. The Centers for Disease Control and Prevention intends to issue a solicitation for scientific and technical services to support the division's public health programs under an indefinite delivery, indefinite quantity contract known as the SHEPheRD Program. Contractors may propose to participate under single or multiple domains. The resultant award will be a multiple award time and materials, labor hour, cost reimbursement, or combination thereof contract with a ceiling price of $90 million over a five year base period and a minimum of $1,000 per contract. Interested parties should monitor the FedBizOpps website where the solicitation is expected to be posted on or about December 1, 2020 to have the opportunity to be considered for any resultant awards.
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Text version
CDC OFR
ACH VENDOR/MISCELLANEOUS PAYMENT
ENROLLMENT FORM
REVISED 8/29/13
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.
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.
AGENCY INFORMATION
FEDERAL PROGRAM AGENCY
CENTERS FOR DISEASE CONTROL & PREVENTION
AGENCY IDENTIFIER:
CDC
AGENCY LOCATION CODE (ALC):
7509-0421
ACH FORMAT:
CCD+ CTX CTP
ADDRESS
P. O. BOX 15580 MS D06
ATLANTA, GA 30333
CONTACT PERSON NAME:
Customer Service
TELEPHONE NUMBER:
(678) 475-4510
ADDITIONAL INFORMATION
FAX (404) 638-5342
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:
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| Bank Name: |
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| Bank Zip: |
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File details come from the government source that posted it. Updated .