Attachment_J-6_EFT_Form.doc

Attachment 7

U.S. Department of Energy

Richland Operations Office

ELECTRONIC FUNDS TRANSFER FORM (EFTF)

31 U.S.C. 3332 requires the Department of Energy to make payments by electronic funds transfer. The information requested herein concerning your organization’s financial institution will be used to make payments by use of electronic funds transfer:

1.

Business Name:

2.

Address:

3. Contact Person for Billings and Payments:

4.

Telephone Number:

5.

Name of Financial Institution:

6.

Address of Financial Institution:

7. Financial Institution’s 9-digit American Banker’s Association (ABA) Identifying Number for Routing Transfer of Funds:

8.

Account Number at your Financial Institution to be Credited with Payments:

9. Organization’s Tax Identification Number (TIN):

10.

Organization's Data Universal Numbering System (DUNS) number:

(This is a 9-character number identifying the business establishment or individual receiving the award. A number can be obtained by calling Dun & Bradstreet, Inc. at 1-800-234-3867.)

11.

Name and Title of Contractor’s Authorizing Official:____________________

12. Signature of Authorizing Official:_______________________________ Remittance advice should be: (please check one)

___ mailed to contact person identified

OR

___ transmitted via e-mail to contact person identified

Email address: