ACH FORM.pdf
PDF 125 KB Posted
- Attached to
- RFP FN1626-26 UNICOR PALLET RACKING INSTALLS
- Solicitation number
- FN1626-26
About this file
This is an ACH Vendor/Miscellaneous Payment Enrollment Form used by UNICOR, Federal Prison Industries, Inc. to process electronic payments to vendors through the Vendor Express Program.
The form collects essential information required for the Treasury Department to transmit payment data electronically to a vendor's financial institution. Required vendor information includes company name, Dun & Bradstreet (DUNS) number, company address, contact person details, and Taxpayer Identification Number (TIN) or Social Security Number (SSN). The financial institution section requires the bank name and address, ACH coordinator contact information, nine-digit routing transit number, depositor account title and number, lockbox number if applicable, and account type (checking, savings, or lockbox). An authorized official must sign the form and provide their telephone number. Vendors must also indicate their business size classification as either Large Business or Small Business. The form specifies UNICOR's agency information, including mailing address at 320 First Street N.W., Washington, D.C. 20534, agency identifier code 15080001, and ACH format as CTX. The Privacy Act statement discloses that information collected is required under 31 U.S.C. 3322 and 31 CFR 210, and that failure to provide requested information may delay or prevent payment receipt through the Automated Clearing House Payment System. The TIN may be used for collecting and reporting delinquent amounts arising from the vendor's relationship with the government.
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Other files
| File | Type | Posted |
|---|---|---|
| FN1626-26 A0001 PALLET RACKING INSTALLS.pdf | ||
| 1620000390_3.pdf | ||
| FN1626-26 SPREADSHEET.xlsx | XLSX spreadsheet | |
| BUSINESS QUESTIONNAIRE.pdf |
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Text version
UNICOR, Federal Prison Industries, Inc.
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.
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. The TIN number submitted may be used for the purposes of collecting and reporting on any delinquent amounts arising out of such person=s relationship with the government.
AGENCY INFORMATION
FEDERAL PROGRAM AGENCY: UNICOR Federal Prison Industries, Inc.
AGENCY IDENTIFIER: UNICOR AGENCY LOCATION CODE (ALC): 15080001 ACH FORMAT: CTX
MAILING ADDRESS: UNICOR, Federal Prison Industries, Inc.
320 First Street N. W., Financial Management Branch, 8th Floor Washington, D.C. 20534
VENDOR PAYMENT CONTACT: E-MAIL: TELEPHONE : FAX:
PAYEE/COMPANY INFORMATION
**You must include your Dun & Bradstreet Number (DUNS #) **
COMPANY NAME: NUMBER: CURRENT DATE:
COMPANY ADDRESS:
CONTACT PERSON: TELEPHONE : E-MAIL: FAX :
TAXPAYER IDENTIFICATION NO (TIN) OR SSN NO: ADDITIONAL INFORMATION:
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
(Check One) SIGNATURE AND TITLE OF AUTHORIZED OFFICIAL:(could be the same as ACH Coordinator) TELEPHONE :
File details come from the government source that posted it. Updated .