Request for Proposals Attachment 9 ACH Vendor Misc Payment Enrollment Form

ATTACHMENT #9

ACH VENDOR / MISCELLANEOUS PAYMENT ENROLLMENT FORM

Payment Information Form
The information requested on this form concerns your financial institution, your account at that institution, and personal information which needs to verified and completed.

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 USC 3322 and 31 CFR 210. This information will be used by the Treasury Department to transmit payment data, by electronic means to your financial institution. Failure to provide the requested information may delay or prevent the receipt of payments through the Automated Clearing House Payment System.

Check one of the following:
108013570441275653570441420433470441
Name: Federal Employee:Offeror:Vendor:

Business
Address:

Remit To
(If same as above, leave blank. Must match address on invoice for internal control purposes.) Address:

Taxpayer Identification # (TIN): (If you are an individual, this may be your Social Security number)

Payee's Telephone Number: ()
908050183515The following information must be completed by your financial institution representative: 0The following information must be completed by your financial institution representative:

Name of Financial
Institution:

Address of Financial Institution:

Financial Institution's 9-digit ABA Routing Number for

Depositor Account Title:_

6. Depositor Account Number:

Type of Account:CheckingSavings

Signature and Title of Authorized Official of Financial Institution:

915669299057************ The following must be signed by the payee************** ************ The following must be signed by the payee**************

762000268605I have verified the information on this form. Signature
_
Date
00I have verified the information on this form.
Signature
_
Date