Attachment 2 ACH EFT Form.doc

RF[-10-0004

ACH VENDOR ENROLLMENT FORM

for Electronic Funds Transfer (EFT)

THIS FORM MUST BE COMPLETED AND RETURNED PRIOR TO PAYMENT

Recent legislation, the Debt Collection Improvement Act, signed by President Clinton, requires Federal agencies to pay vendors and other recipients by Electronic Funds Transfer (EFT). This mandate applies to all recipients who became eligible for a Federal payment after July 26, 1996. Only IRS Tax refunds are exempt from this legislation. Therefore, the contractor is required to provide the Bureau of Engraving and Printing with all the necessary information on this form in order to receive payment. Please return this form to:

Bureau of Engraving and Printing

Office of Procurement

EFT Conversion

14th and C St., SW, Room 708-A

Washington, DC 20228 Agency Information

Federal Program Agency:

Bureau of Engraving and Printing

20135337 ACH Format:

CCD+

Address:

14TH and C st., SW

City:

Washington State:

DC

Zip:

20228

Contact Person Name:

Telephone Number:

Vendor/Company Information

Address:

E-Mail Address:

Financial Institution Information

ACH Bank Name:

Address:

Nine-Digit Routing Transit Number:

Depositor Account Title:

Depositor Account Number:

Type of Account: ( Checking ( Savings

Signature and Title of Authorized Contractor Official:

X

Title:

Telephone Number: ( ) Privacy Act Statement

The following information is provided to comply with the Privacy Act of 1974 (P.L. 83-579). This information will be used by the Treasury Department to transmit payment data, by electronic means to vendor’s financial institution.

Last Revised: 11/13/98

ATTACHMENT 2