Sf-3881

OMB Number: 1510-0056
Expiration Date: 11/30/2012

ACH VENDOR/MISCELLANEOUS PAYMENT
ENROLLMENT FORM

This form is used for Automated Clearing House (ACH) payments with an addendum record that contains payment-related
information processed through the Vendor Express Program. Recipients of these payments should bring this information
to the attention of their financial institution when presenting this form for completion. See reverse for additional
instructions.

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.

AGENCY INFORMATION
Agency Name:

Agency Identifier:

Agency Location Code (ALC):

ACH Format:
CCD+

Address:
Street 1:
Street 2:
City:
County:
State:
Province:
Country:
Zip / Postal Code:
Contact Person Name:
Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
Telephone Number:

Additional Information:

CTX

ACH VENDOR/MISCELLANEOUS PAYMENT
ENROLLMENT FORM
PAYEE/COMPANY INFORMATION
Organization Name (Legal Name):

SSN No. or Taxpayer ID No.:

Address:
Street 1:
Street 2:
City:
County:
State:
Province:
Country:

USA: UNITED STATES

Zip / Postal Code:
Contact Person Name:
Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
Telephone Number:

ACH VENDOR/MISCELLANEOUS PAYMENT
ENROLLMENT FORM
FINANCIAL INSTITUTION INFORMATION
Name of Financial Institution:

Address:
Street 1:
Street 2:
City:
County:
State:
Province:
Country:

USA: UNITED STATES

Zip / Postal Code:
ACH Coordinator Name:
Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
Telephone Number:

Nine-Digit Routing Transit Number:

Depositor Account Title:

Depositor Account Number:

Type of Account:

Lockbox Number:

Checking

Signature and Title of Authorized Official:
Prefix:
First Name:
Middle Name:
Last Name:
Suffix:
Title of Authorized Official:
Telephone Number:

Savings

Lockbox