Form TD F 105.1 TD F 105.1 FRF Assessment Agreement

AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS
FINANCIAL RESEARCH FUND

The information requested on this form is required for the purpose of authorizing the Department of Treasury Financial Research
Fund to electronically collect semiannual assessment payments from your account. Payments will be collected July 20, 2012.
For year 2013 and years subsequent, payments will be collected March 15 and September 15. An electronic billing notification
detailing the amount of the payment will be provided via E-mail approximately 14 days prior to collection. No electronic
collection from your account may be transacted unless a signed authorization form is received. We estimate that it will take
approximately 15 minutes to complete this form. Please submit completed form to TDP@BPD.TREAS.GOV; please include
"FR) Assessments" in the subject line.

CHECK ONE:

START

CHANGE

STOP

BANK INFORMATION
BANK NA ME (PLEASE PRINT)
STREET ADDRESS
CIT Y/STATE:

ZIP CODE:

RSSD ID NUMBER: See Institution Search @

http://www.ffiec.gov/nicpubweb/nicweb/SearchForm.aspx

TAX PAYER IDENTIFICATION NUMBER

PRIMARY CONTACT FULL NAME

PRIMARY PHONE

PRIMARY CONTACT E-MAIL

SECONDARY CONTACT FULL NAME

SECONDARY PHONE

SECONDARY CONTACT E-MAIL

ADDITIONAL CONTACT FULL NAME

ADDITIONAL PHONE

ADDITIONAL CONTACT E-MAIL

I hereby authorize the initiation of a deduction from my account and the Department of Treasury Financial Research Fund to debit
such account. I understand I will be notified of the debit amount, and notified if the debit amount needs to be adjusted, either to be
increased or decreased. I understand that the authorization is in effect until a Change or Stop notice is initiated. I understand that I
must ensure that there are sufficient funds available in my account to perfect the assessment payment.

ACCOUNT INFORMATION
NINE-DIGIT ROUTING TRANSIT NUMBER:
ACCOUNT TITLE
ACCOUNT NUMBER

SIGNATURE AND TITLE OF REPRESENTATIVE

TDF 105.1 (05/2012)

CHECKING
SAVINGS
AREA CODE/TELEPHONE NUMBER

DATE

DEPARTMENT OF THE TREASURY
Dodd-Frank Act (Public Law 111-203)

The Federal government may not conduct or sponsor, and the public is not required to respond to, a collection of information without a currently
valid OMB control number. The control number for this collection is 1505-0245