Attachment 6 - Blank EFT Form.pdf

TO BE COMPLETED BY AIR FORCE : 1099 YES NO

Fax #: Email Address:

EFT ENROLLMENT TYPE: NEW UPDATE CURRENCY TYPE: USD FOREIGN

Name :

Address: Bank Address:

Beneficiary Bank SWIFT CODE:

Taxpayer ID Number (TIN):

Or Social Security Number: Beneficiary Bank Branch Code:

Beneficiary Bank Sort Code (UK Banks):

EFT addenda information required by Contractor to accompany payment

(See item 3 on reverse side) Intermediary Bank

Intermediary BankSWIFT CODE:

Vendor Payment Notification Information

ABA/ ROUTING NUMBER:

IBAN Number:

Bank Account Number:

NAME

Name Of Account, If different than Contractor Name:

EMAIL ADDRESS

ADDITIONAL INFORMATION Account Type: ('X' one of the following)

TELEPHONE NUMBER Checking: Savings:

FAX NUMBER:

Vendor Information Verified and Reviewed By: Template Approved By:

Beneficiary Bank Branch Name:

(80 Characters or less)

Beneficiary Bank Name:

PRIVACY ACT STATEMENT: The information herein is For Official Use Only (FOUO) which must be protected under the Freedom of Information Act of 1966 and Privacy Act of 1974, as amended. Unauthorized disclosure or misuse of this PERSONAL INFORMATION may result in criminal and/or civil penalties. All information collected on this form is required under the provisions of 31 U.S.C. 3332 and 31 CFR 210. PURPOSE: This information will be used by Air Force

Personnel Center Financial Management to transmit payment data, by electronic means to vendor's financial institution. ROUTINE USE: The information collected on this form may be shared with parties' financial institutions for electronic funds transfers (EFT). Failure to provide the requested information may delay or prevent the receipt of payments through the Automated Clearing House (ACH) Payment System or SWIFT/CHIPS Payment Systems.

to transmit payment by electronic means to your financial institution. Return this completed form to the billing address listed on the contract.

BASE NAME:

Comm Phone #:

Contractor Contractor Financial Institution

AFSVC/FMNTC USE ONLY

FOR OFFICIAL USE ONLY

ELECTRONIC FUNDS TRANSFER (EFT)

VENDOR PAYMENT ENROLLMENT FORM

This form is to be used for electronic funds transfer (EFT) payment enrollment. The information will be used by our disbursement office

NOTE: INTERMEDIARY BANK IS REQUIRED FOR ALL USD PAYMENTS TO FOREIGN COUNTRIES

Vendor Information Iput By:

Updated MAR 2023

HURLBURT FIELD, FL

NAFI will initiate payment to Contractor based on the following:

SIGNATURE DATE

4. The bank information contained on this enrollment form signed by Contractor's authorized representative contains the Contractor's correct account information.

Contractor's authorized representative must notify NAFI in writing of any change to said Contractor's bank account information 10 days prior NAFI's forthcoming payment due date. This allows the NAFI to make the necessary account information changes within their EFT payment system. The NAFI will be considered harmless for any loss that may arise solely by reason of error, mistake or fraud regarding the bank information provided by Contractor on an original enrollment or corrected enrollment form.

5. EFT payment is initiated within the normal terms of NAFI's agreement with Contractor. NAFI's EFT terms and conditions neither enlarge or diminish the respective rights and obligations of NAFI within any applicable commercial agreement. The payment due date is not affected. NAFI will consider payment made when Contractor's financial institution has received or has control of the payment transaction. This will generally occur within three (3) calendar days following

EFT payment by the NAFI. Any loss of data at that point will be borne by Contractor unless the loss is due to sole negligence of the NAFI's originating bank.

If the NAFI EFT payment value date is a non-banking day, the EFT value date automatically changes to the next banking business day. In all cases, the banking day is defined as the day the EFT originating bank (NAFI) and the receiving bank (Contractor) is available to transmit and receive the EFT payment.

Contractor should notify the NAFI immediately if payment is not received as described in item 4 (above). The NAFI shall have 10 business days to research and advise said payment.

6. The NAFI has the right to adjust future payments or initiate either an EFT reversal or an ACH debit (with REVERSAL as the entry description) for an EFT payment amount if EFT payment previously paid is a duplicate payment, overpayment, fraudulent payment or payment error.

CONTRACTOR'S AUTHORIZED REPRESENTATIVE

ELECTRONIC PAYMENT TERMS AND CONDITIONS

The Debit Collection Improvement Act of 1996 mandates all Federal government payments be made by Electronic Funds Transfer (EFT) as of 1 Jan 99. As such, payment terms between NAFI and Contractor is by EFT.

Contractor agrees to accept payment from the NAFI through EFT. The NAFI can rely exclusively on the information provided by the Contractor on this enrollment form. This applies to and amends all existing agreements with the NAFI by incorporating the following terms and conditions for electronic payment.

1. EFT payment will be made to the financial institution to credit the account number as stated on enrollment form.

2. EFT payment is in a National Automated Clearing House (NACHA) CCD+ format.

3. Remittance information is limited to repetitive (non-changing) information, such as, customer number, store number, etc.