SF3881-V1.0.pdf
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- Opportunity number
- USDA-NRCS-AL-MULTI-19-GEN0010289
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Department of Agriculture
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ACH Vendor Form
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SF3881
Barbara Williams D:20031024173303Z D:20031105151946- 05'00'
ACH VENDOR/MISCELLANEOUS PAYMENT ENROLLMENT FORM
OMB Number: 1510-0056 Expiration Date: 06/30/2019 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. See reverse for additional instructions.
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.
AGENCY INFORMATION
Agency Name:
Agency Identifier:
Agency Location Code (ALC):
ACH Format:
ACH Format: To be completed by Agency.
Address:
Contact Person Name:
Telephone Number:
Street 1:
Street 2:
City:
County:
State:
Province:
Zip / Postal Code:
Country:
Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
Additional Information:
PAYEE/COMPANY INFORMATION
Organization Name (Legal Name):
SSN No. or Taxpayer ID No.:
Address:
Street 1:
Street 2:
City:
County:
State:
Province:
Zip / Postal Code:
Country:
Contact Person Name:
Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
Telephone Number:
FINANCIAL INSTITUTION INFORMATION
Name of Financial Institution:
Address:
Nine-Digit Routing Transit Number:
Depositor Account Title:
Type of Account:
Signature and Title of Authorized Official:
Street 1:
Street 2:
City:
County:
State:
Province:
Zip / Postal Code:
Country:
ACH Coordinator Name:
Telephone Number:
Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
Depositor Account Number:
Lockbox Number:
Type of Account: Select Type of Account.
Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
Title of Authorized Official:
Telephone Number:
ACH VENDOR/MISCELLANEOUS PAYMENT ENROLLMENT FORM
Agency Name: Enter the Agency Name. This field is required.
| XDPFirstField: |
| Mandatory: |
| Agency Name: Pre-populated from the Application cover sheet.: |
| Agency Identifier: To be completed by Agency.: |
| Agency Location Code: To be completed by Agency.: |
| ACH Format - CCD+: Click to select option.: |
| ACH Format - CTX: Click to select option.: |
| Street1: Enter the first line of the Street Address. This field is required.: |
| Street2: Enter the second line of the Street Address.: |
| City: Enter the City. This field is required.: |
| County: Enter the County.: |
| State: Select the state, US possession or military code from the provided list. This field is required if Country is the United States.: |
| Province: Enter the Province. : |
| Country: Select the Country from the provided list. This field is required.: USA: UNITED STATES |
| Country: Select the Country from the provided list. This field is required.: USA: UNITED STATES |
| Zip / Postal Code: Enter the Postal Code (e.g., ZIP code). This field is required if Country is the United States. : |
| DataEntered: |
| Prefix: Select the Prefix from the provided list or enter a new Prefix not provided on the list.: |
| First Name: Enter the First Name. This field is required.: |
| Middle Name: Enter the Middle Name.: |
| Last Name: Enter the Last Name. This field is required.: |
| Suffix: Select the Suffix from the provided list or enter a new Suffix not provided on the list.: |
| Telephone Number: Enter the daytime Telephone Number. This field is required.: |
| Additional Information: To be completed by Agency.: |
| Organization Name: Enter the legal name of the applicant that will undertake the assistance activity. This field is required.: |
| SSN/TIN: Enter either SSN or TIN as assigned by the Internal Revenue Service. If your organization is not in the US, enter 44-4444444. This field is required.: |
| Telephone Number: Enter the daytime Telephone Number. This field is required.: |
| Institution Name: Enter name of financial institution. This field is required.: |
| Nine-Digit Routing Transit Number: Enter Nine-Digit Routing Transit Number. Numbers only. This field is required.: |
| Depositor Account Title: Enter Depositor Account Title. This field is required.: |
| Depositor Account Number: Enter Depositor Account Number. This field is required.: |
| Lockbox Number: Enter Lockbox Number.: |
| Type of Account - Checking: Click to select option.: |
| Type of Account - Savings: Click to select option.: |
| Type of Account - Lockbox: Click to select option.: |
| Title of Authorized Official: Enter title of authorized official. This field is required.: |
| Telephone Number: Enter the daytime Telephone Number. This field is required.: |
| LastField: |
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