VendorACHForm.doc

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.

MAILING ADDRESS: UNICOR, Federal Prison Industries, Inc.

VENDOR PAYMENT CONTACT:

E-MAIL:

TELEPHONE :

FAX:

PAYEE/COMPANY INFORMATION

**You must include your Dun & Bradstreet Number (DUNS #) **

COMPANY ADDRESS:

BUSINESS SIZE:

Large ___ Small ___ Small Disadvantaged ___ Woman Owned Small Business ___ Other __________________

FINANCIAL INSTITUTION INFORMATION

NAME:

ADDRESS:

NINE DIGIT ROUTING TRANSIT NUMBER:

DEPOSITOR ACCOUNT TITLE:

TYPE OF ACCOUNT: ___ CHECKING ___ SAVINGS ___ LOCKBOX

(Check One)

SIGNATURE AND TITLE OF AUTHORIZED OFFICIAL:(could be the same as ACH Coordinator)

TELEPHONE :

Located on check or deposit slip at very bottom.