Form SF3881 ACH Vendor/Miscellaneous Payment Enrollment Form

OMB No.: 1510-0056

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

FEDERAL PROGRAM AGENCY
AGENCY IDENTIFIER:

AGENCY LOCATION CODE (ALC):

ACH FORMAT:
CCD+

CTX

ADDRESS:

CONTACT PERSON NAME:

TELEPHONE NUMBER:

ADDITIONAL INFORMATION:

PAYEE/COMPANY INFORMATION
NAME

SSN NO. OR TAXPAYER ID NO.

ADDRESS

CONTACT PERSON NAME:

TELEPHONE NUMBER:

FINANCIAL INSTITUTION INFORMATION
NAME:
ADDRESS:

ACH COORDINATOR NAME:

TELEPHONE NUMBER:

NINE-DIGIT ROUTING TRANSIT NUMBER:
DEPOSITOR ACCOUNT TITLE:
DEPOSITOR ACCOUNT NUMBER:
TYPE OF ACCOUNT:

LOCKBOX NUMBER:
CHECKING

SAVINGS

LOCKBOX

SIGNATURE AND TITLE OF AUTHORIZED OFFICIAL: (Could be the same as ACH Coordinator)

TELEPHONE NUMBER:

AUTHORIZED FOR LOCAL REPRODUCTION

SF 3881 (Rev. 1/2016)
Prescribed by Department of the Treasury
31 U S C 3322; 31 CFR 210

INSTRUCTIONS FOR COMPLETING SF 3881 FORM
Make three copies of form after completing. Copy 1 is the Agency Copy; copy 2 is the Payee/Company Copy; and copy 3
is the Financial Institution Copy.

1.

Agency Information Section - Federal agency prints or types the name and address of the Federal program
agency originating the vendor/miscellaneous payment, agency identifier, agency location code, contact person
name and telephone number of the agency. Also, the appropriate box for ACH format is checked.

2.

Payee/Company Information Section - Payee prints or types the name of the payee/company and address that
will receive ACH vendor/miscellaneous payments, social security or taxpayer ID number, and contact person
name and telephone number of the payee/company. Payee also verifies depositor account number, account
title, and type of account entered by your financial institution in the Financial Institution Information Section.

3.

Financial Institution Information Section - Financial institution prints or types the name and address of the
payee/company's financial institution who will receive the ACH payment, ACH coordinator name and telephone
number, nine-digit routing transit number, depositor (payee/company) account title and account number. Also,
the box for type of account is checked, and the signature, title, and telephone number of the appropriate
financial institution official are included.

BURDEN ESTIMATE STATEMENT
The estimated average burden associated with this collection of information is 15 minutes per respondent or
recordkeeper, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and
suggestions for reducing this burden should be directed to the Bureau of the Fiscal Service, Forms Management Officer,
Parkersburg, WV 26106-1328.