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22 <br /> OMB No.1510-0055 <br /> ACH VENDOR/MISCELLANEOUS PAYMENT <br /> ENROLLMENT FORM <br /> This form is used for Automated Clearing House (ACH) payments with an addendum record that contains <br /> payment-related information processed through the Vendor Express Program. Recipients of these payments <br /> should bring this information to the attention of their financial institution when presenting this form for <br /> completion. See reverse for additional instructions. <br /> PRIVACY ACT STATEMENT <br /> The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). All <br /> information collected on this form is required under the provisions of 31 U.S.C. 3322 and 31 CFR 210. <br /> This information will be used by the Treasury Department to transmit payment data, by electronic means <br /> to vendor's financial institution. Failure to provide the requested information may delay or prevent the <br /> receipt of payments through the Automated Clearing House Payment System. <br /> AGENCY INFORMATION <br /> FEDERAL PROGRAM AGENCY <br /> AGENCY IDENTIFIER: AGENCY LOCATION CODE(ALC): ACH FORMAT: <br /> ❑CCO+ n CTX <br /> ADDRESS: <br /> CONTACT PERSON NAME: TELEPHONE NUMBER: <br /> ADDITIONAL INFORMATION: <br /> PAYEE/COMPANY INFORMATION <br /> NAME SSN NO.OR TAXPAYER ID NO <br /> ADDRESS <br /> • <br /> CONTACT PERSON NAME: 'TELEPHONE NUMBER: <br /> { <br /> FINANCIAL INSTITUTION INFORMATION <br /> NAME: <br /> ADDRESS: <br /> ACH COORDINATOR NAME. TELEPHONE NUMBER: <br /> NINE-DIGIT ROUTING TRANSIT NUMBER: { } <br /> DEPOSITOR ACCOUNT TITLE: <br /> DEPOSITOR ACCOUNT NUMBER: LOCKBOX NUMBER: <br /> TYPE OF ACCOUNT: <br /> ❑CHECKING ❑SAVINGS ❑LOCKBOX <br /> SIGNATURE AND TITLE OF AUTHORIZED OFFICIAL: TELEPHONE NUMBER: <br /> (Could be the same as ACH Coordinator) <br /> AUTHORIZED FOR LOCAL REPRODUCTION { SF 3881(Rev.212003) <br /> Prescribed by Department of Treasury <br /> 31 U S C 3322;31 CFR 210 <br />