190-F-05-001 Fellowship Stipend Payment Enrollment Form

United States
ENVIRONMENTAL PROTECTION AGENCY
Washington, DC 20460

OMB Control No. 2030-0020
Approval expires 04/30/2012
For internal use only

FELLOWSHIP STIPEND PAYMENT
ENROLLMENT FORM
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.

EPA INFORMATION
FEDERAL PROGRAM AGENCY

U.S. ENVIRONMENTAL PROTECTION AGENCY
AGENCY IDENTIFIER:

AGENCY LOCATION CODE (ALC):

LVFC

68128933

ADDRESS:

PO BOX 98515
LAS VEGAS, NV 89193-8515
CONTRACT PERSON NAME:

LUIS E RIVERA

TELEPHONE NUMBER

EMAIL: Rivera.LuisE@EPA.GOV

(702) 798-2495

ADDITIONAL INFORMATION

FAX NUMBER (702) 798-2423
FELLOW’S INFORMATION
NAME

SOCIAL SECURITY NUMBER

ASSISTANCE ID/FELLOWSHIP NUMBER
ADDRESS
CONTACT PERSON EMAIL ADDRESS:

TELEPHONE NUMBER:

(

)

FELLOW’S BANK INFORMATION (STIPEND WILL BE SENT TO YOUR BANK BY EFT)
BANK NAME:
BANK ADDRESS:

NINE-DIGIT ROUTING TRANSIT NUMBER:
NAME ON ACCOUNT:
ACCOUNT NUMBER:
TYPE OF ACCOUNT:
CHECKING
FELLOW’S AUTHORIZING SIGNATURE:

SAVINGS
TELEPHONE NUMBER:

(

EPA 190-F-05-001

)

NOTE: The intention of this form is to establish Direct Deposit for Stipends payable to Fellowship recipients. This is not a
mandatory requirement but highly recommended. If you don’t have a bank account - DO NOT FILL OUT THIS FORM,
instead your Stipend will be forwarded by check via mail.
Instructions for the Fellowship Stipend Payment Enrollment Form:
Under FELLOW’S INFORMATION:
- Enter your name
- Enter your Social Security Number
- Enter your Assistance ID/Fellowship Number (it usually starts with U, FP or MA, located on the top center of your
Fellowship Agreement)
- Enter your mailing address
- Enter your email address
- Enter your telephone number
Under FELLOW’S BANK INFORMATION:
- Enter your banking institutions name
- Enter your banking institutions complete address (local bank address only)
- Enter your nine-digit routing number (see illustration)
- Enter the name the account is under (your name or parents, etc.)
- Enter your bank account number (see illustration)
- Enter what type of account (Checking or Savings)
- Enter signature and telephone number

Routing Number

Acct Number

Do not use

(Do not use the numbers from a deposit slip)

The public reporting and recordkeeping burden for this collection of information is estimated to average 30 minutes per response.
Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for
minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division,
U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in
any correspondence. Do not send the completed form to this address.

EPA 190-F-05-001