Form ACH Form ACH Form Authorizaton Agreeement for Electronic Funds Transfer Pa

NATIONAL CREDIT UNION ADMINISTRATION
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER PAYMENTS
In accordance with the Debt Collection Improvement Act of 1996 (Public Law 104-134), the National Credit Union
Administration (NCUA) must make payments to credit unions by Electronic Funds Transfer (EFT).
PART I – MUST BE COMPLETED – Please print
NCUA CHARTER NUMBER (FCU) OR INSURANCE CERTIFICATE (FISCU) ___________________________
CREDIT UNION NAME_______________________________________________________________________
ADDRESS __________________________________________________________________________
CITY _____________________________________ __________ STATE ________ ZIP____________
EMPLOYER’S ID NO. [TAXPAYER ID NO].________________________________________________
CONTACT PERSON __________________________________ PHONE NO. ___________________
EMAIL _____________________________________________________________________________
FINANCIAL INSTITUTION NAME ______________________________________________________________
9-DIGIT ROUTING & TRANSIT NO. (RTN)_________________________________________________
ACCOUNT NO. ______________________________________________________________________
(must be at least 4 digits, and only contain numbers, spaces, or dashes)
If using a corporate credit union, please call your corporate to verify correct RTN and account info for ACH use.

PART II – OPTIONAL
As a convenience to credit unions, NCUA is now using a Treasury-developed program, Pay.Gov, to accept
electronic credit union payments to NCUA via direct debit on the invoice due date using the account info above.
If you do not elect Pay.Gov as a method of payment to NCUA, you must pay NCUA invoices by check.

… Yes, please direct debit my credit union’s invoiced amounts through Pay.Gov.
PART III – MUST BE COMPLETED
I authorize NCUA to initiate electronic funds transfer payments to the credit union (and from the credit union if Pay.Gov
option was elected).
This authorization replaces all previous authorizations and remains in full force and effect unless NCUA receives a new
authorization, 60 days prior to the next established payment date.

NAME OF AUTHORIZED
REPRESENTATIVE____________________________________ TITLE_____________________________
Please Print
Please Print
SIGNED_______________________________________________ DATE ___________________________
PLEASE KEEP A COPY FOR YOUR RECORDS.
Please complete and return to:
By Fax to:
703-837-2400

National Credit Union Administration
OR
By Mail to:
National Credit Union Administration
Office of the Chief Financial Officer
1775 Duke Street
Alexandria, VA 22314-3428
OMB No. 3133-0135 9/30/06

PAPERWORK REDUCTION ACT STATEMENT: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The time
required to complete this collection of information is estimated to average 15 minutes per response. This includes time for reviewing the instructions, gathering needed infomration, and completing and reviewing the
information. If you have comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, send comments to: NCUA, OCFO, 1775 Duke Street,
Alexandria, Virginia 22314-3428.