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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 f these payments <br /> should bring this information n t 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 1 974 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 ent data, by electronic means <br /> to vendor 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 /> ATI <br /> [FEDERAL PROGRAM AEI <br /> A iNCY IDENTIFIER: AGENCY INFORM:AGENCY LOCATION C a : ACH FORMAT: <br /> MAT, <br /> i cap+ fl CT <br /> ADDRESS: <br /> CbNTA T PERSON NAME: 'TELEPHONE NUMBER:. <br /> ADDITIONAL INFORMATION; <br /> �........ .. PA COMPANY INFORMATION <br /> NAME <br /> Ik NO,ORTAXPAYER ID NO_ <br /> L... . <br /> FCTITACT PER IAl E:— <br /> *TELEPHONE NUMBER:. <br /> r <br /> 3INANCIALTNSTITIihON INFORMATION <br /> NAME: .... . . <br /> ADDRESS: <br /> ACH COORDINATOR NAME; TELEPHONE NUMBER: <br /> ICI DIGIT ROUTING TRANSIT NUMBER: �— <br /> DEPOSITOR ACCOUNT TITLE: <br /> DEPOSITOR ACCOUNT NUMBER; <br /> LOCKBOX NUMBER: <br /> L. <br /> TYPE OF ACCOUNT: <br /> CHECKING LI SAVINGS D LOCKOO <br /> r I O NAT URE AND TITLE OF AUTHORIZED OFFICIAL TELEPHONE NUMBER: <br /> (Could be the same as ACH Coordinator) <br /> AUTHORIZED FOR LOCAL REPRODUCTION Prescribed by Department of Treasury <br /> 31 U S C 3322;31 CFR 210 <br />