ACH FORM 2024.pdf
PDF 99 KB Posted
- Attached to
- FPI EL RENO PLASMA TABLE
- Solicitation number
- FN1578-24
About this file
The provided document is an ACH Vendor/Miscellaneous Payment Enrollment Form from UNICOR, Federal Prison Industries, Inc. 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. The form collects the vendor's banking information, including the account number, routing number, and account type. It also requires the vendor's Dun & Bradstreet Number (DUNS #) and Taxpayer Identification Number (TIN). The form is submitted to UNICOR, Federal Prison Industries, Inc., which is the federal agency associated with the related contract opportunity.
The related federal contract opportunity is for a Plasma Table for FPI EL RENO, solicitation number FN1578-24, issued by the Department of Justice Bureau of Prisons Correctional Facilities. The solicitation is for civilian federal agency requirements.
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Other files
| File | Type | Posted |
|---|---|---|
| CONTRACTING BUSINESS MANGAGEMENT QUESTIONNAIRE.pdf | ||
| SOLICITATION FN 1578-24.pdf | ||
| WAGE DETERMINATION RATES.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:
UNIQUE ENTITY ID 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 :
Business Size ___ Large Business ____Small Business lkerr Cross-Out
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