36C24719R0149-003.pdf

WACO VEND ACH VENDOR/MISCELLANEOUS PAYMENT OMB No. 1510-0056 New Vendor 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.

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 thru the Automated Clearing House Payment System.

FEDERAL PROGRAM AGENCY

Dept of Veterans Affairs -- Financial Services Center

AGENCY IDENTIFIER: AGENCY LOCATION CODE (ALC)

111036183 36001200

PO Box 149971 Austin, TX 78714-9971

CONTACT PERSON NAME: TELEPHONE NUMBER

Customer Support Help Desk - Vendorizing 254-297-5438

ADDITIONAL INFORMATION:

Fax back completed form to (512)460-5221 Visit http- http://www.fms.treas.gov or call 1-877-353-9791 for questions

Check One: VA Employee CWT/IT Worker Other Individual Company MLAC/LGY Utility

1. PREVIOUS NAME (IF CHANGING INFORMATION) 2. PREVIOUS SSN NO. OR TAXPAYER ID NO.

3. CURRENT NAME 4. CURRENT SSN NO. OR TAXPAYER ID NO.

5. ADDRESS

6. CITY, STATE, ZIP 7. TELEPHONE NUMBER:

8. CONTACT PERSON NAME: 9. COMMENTS:

FINANCIAL INSTITUTION INFORMATION

10. BANK NAME

11. BANK ADDRESS

12. CITY, STATE, ZIP

13. ACH COORDINATOR NAME: 14. TELEPHONE

15. NINE-DIGIT ROUTING TRANSIT NUMBER:

16. DEPOSIT ACCOUNT TITLE:

17. DEPOSIT ACCOUNT NUMBER:

18. TYPE OF ACCOUNT (check one): 19. ACH FORMAT (check one):

Checking Savings CCD+

CTX

20. SIGNATURE OF PAYEE 21. TELEPHONE NUMBER:

/S/ DATE ( )

SF 3881 (Rev 12/90) Vend Team Revision 8/13/02

SF 3881 INSTRUCTIONS

Top of the Form: Circle if this information is an addition or a change to existing vendor information. Sta Number is the VA station with which the vendor is doing business, Sta contact is the name of a person at the station to contact and their telephone number.

The station number is identified in the first three digits of the purchase order number for your invoice.

1. Previous Name: If there is a change in name please input previous name.

2. Previous SSN or TIN: If there is a change in SSN or TIN please input previous SSN or TIN.

3. Current Name: Current name of company or individual.

4. Current SSN or TIN: Current Social Security Number if an Individual or Taxpayer ID if a company or business.

5. Address: Current correspondence address. If not putting EFT information, please put current remit to address.

6. City, State, Zip: Input city, state and zip code for address.

7. Telephone Number: Current telephone number of contact name to include 3 digit area code.

8. Contact Person Name: Name of person to contact for any questions or concerns regarding the information filled out.

9. Comments: Any additional comments pertinent to this form

10. Bank Name: Name of the bank that will handle financial transactions.

11. Bank Address: Current address of the bank.

12. City, State, Zip: Same as above.

13. ACH Coordinator Name: Name of person at the bank that handles ACH banking transactions.

(The bank may be contacted for that information.)

14. Telephone: Telephone number of the ACH Coordinator

15. Nine Digit Routing Transit Number: Nine digit bank routing number (must start with a number less than 5) used for ACH transfers. Number may be received from the bank or from a check.

(The number on the deposit slip may not be utilized as the bank rounting number.)

16. Deposit Account Title: Name on the bank account.

17. Deposit Account Number: Account number with the bank.

18. Type of Account: Choose one, checking or savings.

19. ACH Format: Choose one, CCD+= one deposit for every invoice, CTX= one deposit per day regardless of number of invoices. There may be a difference in the information transmitted on the electronic addendum record. Call 1-877-353-9791 for further clarification.

20. Signature: Signature of payee. This document must be signed for information to be changed or entered.

21. Telephone Number: Telephone number of the person who signed the document.

22. Please let us know when you have changed banks of bank account number by filling out and faxing this form to (512) 460-5239.

23. Failure to submit this form anytime there is a bank or account change may cause payments to reject, which will cause a delay in receipt of the payment.

Form W -9 (Rev. October 2007) Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Give form to the requester. Do not send to the IRS.

Name (as shown on your income tax return)

Business name, if different from above

Other (see instructions) ©

Check appropriate box: Individual/Sole proprietor Corporation Partnership Limited liability company. Enter the tax classification (D=disregarded entity, C=corporation, P=partnership) ©

Address (number, street, and apt. or suite no.)

City, state, and ZIP code

List account number(s) here (optional)

Requester’s name and address (optional)

Exempt payee

Part I Taxpayer Identification Number (TIN)

Social security number or

Employer identification number

Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter.

Part II Under penalties of perjury, I certify that:

Certification

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal

Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and

3. I am a U.S. citizen or other U.S. person (defined below).

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply.

For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must provide your correct TIN. See the instructions on page 4.

Signature of U.S. person Date ©

Sign Here

General Instructions Section references are to the Internal Revenue Code unless otherwise noted.

Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA.

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to:

1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),

2. Certify that you are not subject to backup withholding, or

3. Claim exemption from backup withholding if you are a U.S.

exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners’ share of effectively connected income.

Note. If a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9.

Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are:

● An individual who is a U.S. citizen or U.S. resident alien,

● A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States,

● An estate (other than a foreign estate), or

● A domestic trust (as defined in Regulations section 301.7701-7).

Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax on any foreign partners’ share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax.

Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S.

status and avoid withholding on your share of partnership income.

The person who gives Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States is in the following cases:

● The U.S. owner of a disregarded entity and not the entity,