ACH_FORM.PDF

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:

VENDOR PAYMENT CONTACT:

E-MAIL:

TELEPHONE :

FAX:

PAYEE/COMPANY INFORMATION **You must include your Dun & Bradstreet Number (DUNS #) **

COMPANY NAME:

DUN & BRADSTREET NUMBER:

EFFECTIVE DATE:

COMPANY ADDRESS:

CONTACT PERSON:

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)