ACH Vendor Form.doc

USCP Form CP ACH (10-00)

VENDOR

ENROLLMENT FORM

This form is used for adding or updating USCP vendors in the Momentum Financial System. Required fields are marked with an asterisk (*). If vendor is to be paid by ACH (electronically), their banking information (“Financial Institution Information”) must also be filled out; If paid only by check or purchase card, it should be left blank.

AGENCY INFORMATION

FEDERAL PROGRAM AGENCY:

United States Capitol Police

ADDRESS:

119 D. Street, NE, Washington D.C. 20510-7218

SYSTEMS CONTACT STAFF:

Debra Barnwell, James David Cauthon, or Susan West

TELEPHONE NUMBER:

202-593-3524, 3522, or 3523

* NAME OF USCP STAFF REQUESTING VENDOR ADD/CHANGE: Deborah Jackson

* TYPE OF PURCHASE: Check one:

FORMCHECKBOX

Purchase Card FORMCHECKBOX Order

* Is this a new vendor? If “NO”, then which information is changing?

PAYEE / COMPANY INFORMATION

* VENDOR NAME:

* 9-DIGIT SSN OR TAXPAYER ID NO:

IS THIS AN EIN OR SSN?

* REMITTANCE ADDRESS:

* MAILING ADDRESS, IF DIFFERENT:

* PHYSICAL ADDRESS, IF DIFFERENT:

* ARE YOU A 1099 VENDOR?

* ARE YOU A GOVERNMENT AGENCY? If Yes, check one: FORMCHECKBOX Federal FORMCHECKBOX State:

* SOCIO-ECONOMIC INFO: Check one of the following, if appropriate:

FORMCHECKBOX

Woman Owned FORMCHECKBOX Minority Owned FORMCHECKBOX Small Business FORMCHECKBOX Other (Specify)

CONTACT PERSON NAME:

TELEPHONE NUMBER:

FINANCIAL INSTITUTION INFORMATION

*REQUIRED ONLY IF VENDOR IS PAID BY ACH

FINANCIAL INSTITUTION NAME:

NINE-DIGIT ROUTING TRANSIT NUMBER:

DEPOSITOR ACCOUNT NUMBER:

TYPE OF ACCOUNT: FORMCHECKBOX

Corporate Checking FORMCHECKBOX Personal Checking FORMCHECKBOX Savings FORMCHECKBOX Lockbox