UNICORACH.pdf
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About this file
This is an ACH Vendor/Miscellaneous Payment Enrollment Form used by UNICOR (Federal Prison Industries, Inc.) to process electronic payments to vendors through the Vendor Express Program.
The form collects essential vendor banking information required for Automated Clearing House (ACH) payments in CTX format. Vendors must provide company details including legal name, Dun & Bradstreet Number (DUNS #), Taxpayer Identification Number (TIN) or Social Security Number, and complete contact information. Financial institution information required includes the bank name and address, ACH coordinator name and phone number, nine-digit routing transit number, depositor account title and number, and account type (checking, savings, or lockbox). The form must be signed by an authorized official with their title and telephone number. UNICOR's mailing address is PO Box 11849, Lexington, KY 40578-1849, with vendor payment inquiries directed to Carla Coleman at Carla.Coleman@usdoj.gov, 800-827-3168 ext. 3308, or fax 859-253-8877. The form serves as a template for vendors to enroll in the ACH payment system, with all collected information governed by the Privacy Act of 1974 and used by the Treasury Department to transmit payment data electronically.
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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 .