UNICORACH.pdf
PDF 84 KB Posted
- Attached to
- Slide Fasteners
- Solicitation number
- CT2375-25
About this file
The document is an ACH Vendor/Miscellaneous Payment Enrollment Form from UNICOR, Federal Prison Industries, Inc. The form is used for setting up automated electronic payments through the Vendor Express Program, requiring vendors to provide comprehensive financial and contact information. The form mandates inclusion of details such as the company's Dun & Bradstreet Number, taxpayer identification number, financial institution routing information, and account type. UNICOR's agency location code is 15080001, with a payment contact named Carla Coleman who can be reached at 800-827-3168, x3308 or Carla.Coleman@usdoj.gov. The form includes a Privacy Act statement explaining that the collected information is required under 31 U.S.C. 3322 and 31 CFR 210 for transmitting payment data electronically to the vendor's financial institution.
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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.
PO Box 11849 Lexington, KY 40578-1849
VENDOR PAYMENT CONTACT:
Carla Coleman
E-MAIL:
Carla.Coleman@usdoj.gov
TELEPHONE :
800-827-3168, x3308
FAX:
859-253-8877
PAYEE/COMPANY INFORMATION You must include your Dun & Bradstreet Number (DUNS #)
COMPANY NAME: DUN & BRADSTREET 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 :
File details come from the government source that posted it. Updated .