RD 1951-65 Customer Initiated Payments Enrollment Form

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Form Approved
OMB No. 0575-0184

Form RD 1951-65
(07-10)

U.S. Department of Agriculture
Rural Development - St. Louis, Missouri
Customer Initiated Payments (CIP) Enrollment Form
Please process my request pertaining to the Customer Initiated Payments (CIP) program which uses the Automated Clearing House
(ACH) to pay my Rural Development loan. I understand that the CIP/ACH payments will only be made after my organization schedules
the payment on the CIP system.
Current Date:

Effective Date of Action:

Action Requested:

Add

Change

Delete

BORROWER INFORMATION
Reference No. /
Primary Borrower ID:
Borrower Name:
Address:
City/State//Zip:
Contact Person/Title:

(Please Print)
(Signature Only)

Signature of Contact:
Telephone No.:

(

)

Fax No.:

(

)

BANKING INFORMATION
New Banking Information

Old Banking Information
Bank Routing Transit No.:
Bank Account No.:
Bank Acct Type:

Checking

Savings

General
Ledger

Checking

Savings

General
Ledger

Bank Account Nickname:
If adding or changing routing transit number or bank account, please send a VOIDED check or deposit slip.
Fax this completed form and attachments to:

or

Mail this completed form with attachments to:
USDA Rural Development
ATTN: Cash Management Branch
Bldg 104/FC-363
4300 Goodfellow Blvd.
St. Louis, MO 63120

USDA/Rural Development
Cash Management Branch
314-457-4370

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0575-0184. The time
required to complete this information collection is estimated to average 30 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Privacy Act Statement
The following information is provided to comply with the Privacy Act of 1974 (P. L. 93 -579). The information requested on the form is required under
various provisions of title 15 U.S.C. 1601, 12 CFR 205 and 31 CFR 202, for the purpose of providing the authority to the Department of Treasury to
designate financial institutions to collect payments, by electronic means, from your account. The information will be used for identification with the
records of the government agency and the financial institution to direct your payments to the point you authorize.

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