ACH Form.pdf

ACH VENDOR/MISCELLANEOUS PAYMENT

ENROLLMENT FORM

OMB No. 1510-0056

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.

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.

PRIVACY ACT STATEMENT

AGENCY INFORMATION

FEDERAL PROGRAM AGENCY

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

CCD+ CTX

ADDRESS:

CONTACT PERSON NAME: TELEPHONE NUMBER:

ADDITIONAL INFORMATION:

PAYEE/COMPANY INFORMATION

NAME

ADDRESS

CONTACT PERSON NAME: TELEPHONE NUMBER:

SSN NO. OR TAXPAYER ID NO.

FINANCIAL INSTITUTION INFORMATION

NAME:

ADDRESS:

ACH COORDINATOR NAME: TELEPHONE NUMBER:

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)

TELEPHONE NUMBER:

SF 3881 (Rev. 2/2003 ) Prescribed by Department of Treasury

31 U S C 3322; 31 CFR 210

AUTHORIZED FOR LOCAL REPRODUCTION