ACH VendorMiscellaneous Payment Enrollment Form.pdf

PDF 16 KB Posted

Attached to
Qatari Audience Analysis Federal grant opportunity
Opportunity number
PAS-QAT-FY20-001
Issued by
Department of State US Embassy Doha

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ACH VendorMiscellaneous Payment Enrollment Form

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ACH VENDOR/MISCELLANEOUS PAYMENT

ENROLLMENT FORM

OMB Number: 1530-0069 Expiration Date: 06/30/2022

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

Agency Name:

Agency Identifier: Agency Location Code (ALC): ACH Format:

CCD+ CTX

Address:

Contact Person Name:

Telephone Number:

Street 1:

Street 2:

City:

County:

State:

Province:

Zip / Postal Code:

Country:

Prefix:

First Name:

Middle Name:

Last Name:

Suffix:

Additional Information:

PAYEE/COMPANY INFORMATION

Organization Name (Legal Name):

SSN No. or Taxpayer ID No.:

Address:

Street 1:

Street 2:

City:

County:

State:

Province:

Zip / Postal Code:

Country:

Contact Person Name:

Prefix:

First Name:

Middle Name:

Last Name:

Suffix:

Telephone Number:

USA: UNITED STATES

FINANCIAL INSTITUTION INFORMATION

Name of Financial Institution:

Address:

Nine-Digit Routing Transit Number:

Depositor Account Title:

Type of Account:

Signature and Title of Authorized Official:

Street 1:

Street 2:

City:

County:

State:

Province:

Zip / Postal Code:

Country:

ACH Coordinator Name:

Telephone Number:

Prefix:

First Name:

Middle Name:

Last Name:

Suffix:

Depositor Account Number: Lockbox Number:

Checking Savings Lockbox

Prefix:

First Name:

Middle Name:

Last Name:

Suffix:

Title of Authorized Official:

Telephone Number:

USA: UNITED STATES

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