Form FS Form 2888 FS Form 2888 Application Form for U.S. Department of the Treasury Acc

APPLICATION FORM FOR U.S. DEPARTMENT OF THE TREASURY
ACCOUNTABLE OFFICIAL STORED VALUE CARD (SVC)

OMB No. 1530-0020
EXP. DATE 09/30/2019

DIRECTIONS: Submit completed form to Disbursing or Finance Office. Provide bank or credit union information if you are authorized to transfer funds from an agency bank or
credit union account to your Accountable Official Treasury Stored Value Card (SVC) account at a Treasury SVC kiosk.
ACCOUNTABLE OFFICIAL PERSONAL INFORMATION
1. RATE, RANK, TITLE

5. PAY GRADE

2. FIRST NAME

6. MILITARY BRANCH OR
COMPANY NAME

3. MIDDLE INITIAL

7. FULL SSN

4. LAST NAME

8. DATE OF BIRTH
(MMDDYYYY)

9. MOTHER’S MAIDEN NAME OR KEYWORD
(Required for security purposes)

10a. MILITARY DUTY ADDRESS (For Navy/Marine Cash include assigned Division, Unit, etc.) OR WORK ADDRESS (Contractors)
b. CITY

c. STATE

d. ZIP CODE

c. STATE

d. ZIP CODE

e. COUNTRY

11a. RESIDENCE/PERMANENT ADDRESS (Must not be military duty address)
b. CITY
12. WORK TELEPHONE NUMBER

13. CELL PHONE NUMBER

e. COUNTRY

14. E-MAIL ADDRESS
NONE

ACCOUNTABLE OFFICIAL BANK OR CREDIT UNION INFORMATION
15a. BANK OR CREDIT UNION NAME
16. ABA ROUTING NUMBER (9-digit number)

b. CITY

c. STATE

d. ZIP CODE

17. ACCOUNT NUMBER

18. ACCOUNT NAME (Name as it appears on your account)

19. ACCOUNT TYPE (X one)
CHECKING

SAVINGS

ACCOUNTABLE OFFICIAL LIABILITY: I acknowledge that I am the Accountable Official for all funds placed on this card and may be held pecuniarily liable for the loss or
misuse of such funds. I may be relieved of such liability only under the procedures detailed in DoD FMR Volume 5, Chapter 1.
EXPIRED, LOST, STOLEN, OR DAMAGED CARD: When the Accountable Official Treasury SVC card expires, any value remaining may be forwarded to the bank or credit
union account specified above. If the account has been closed or if any value remaining on the Treasury SVC cannot be forwarded to the account for any other reason, I
understand that the funds may be transferred to an account in the U.S. Treasury in accordance with 31 U.S.C. 1322 or elsewhere in accordance with applicable law. The
agency listed in Item 18 retains the right to claim such funds. If my Accountable Official Treasury SVC is lost, stolen, or damaged, I may be charged a fee for a replacement
card.
ADDITIONAL TERMS AND CONDITIONS: By using the Accountable Official Treasury SVC, I agree to accept the terms and conditions for use of the Accountable Official
Treasury SVC established by the issuer of the card. This form may be imaged and kept on file electronically by the U.S. Department of the Treasury and/or its Financial or
Fiscal Agent, and an electronic image shall be considered the legal equivalent of the original. I represent and warrant that the agency listed in Item 18 has authorized me to
obtain this Accountable Official Treasury SVC, to link it to the bank or credit union account listed above, and to hold, collect, and disburse funds that are in the account and on
this Accountable Official Treasury SVC. I agree to return the Accountable Official Treasury SVC when I no longer hold the position as accountable office for the funds and/or
Accountable Officer SVC account.
PRIVACY ACT STATEMENT
AUTHORITY: Executive Order 9397, 31 CFR 210, and 31 U.S.C. 7701.
PRINCIPAL PURPOSES: To enroll individuals acting in the capacity of Accountable Officials in the Treasury SVC program; to obtain authorization to initiate debit and credit
entries to bank and credit union accounts; and to facilitate collection of any delinquent amounts.
ROUTINE USES: The information on this form may be disclosed as generally permitted under 5 U.S.C. Section 552a(b) of the Privacy Act of 1974, as amended. It may be
disclosed outside of the U.S. Department of the Treasury, Fiscal and Financial Agents involved in providing SVC services, and their contractors or to the Department of
Defense (DoD) for the purpose of administering the Treasury SVC programs. In addition, other Federal, State, or local government agencies that have identified a need to
know may obtain this information for the purpose(s) identified by the Bureau of the Fiscal Service (Fiscal Service) Routine Uses as published in the Federal Register.
Aggregate data about transactions captured both on and off the installation or ship, whether through the card’s electronic purse or magnetic strip, may be used to generate
summary level reports.
DISCLOSURE: Disclosure is voluntary; however, failure to furnish requested information may prevent you from participating in the Treasury SVC programs. Your SSN is
being requested to verify your identify and to facilitate the collection of any amounts that may become due to the government as a result of your use of the Treasury SVC. If
you do not provide your SSN, we cannot process your application for an SVC.
BURDEN ESTIMATE 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 information collection is estimated to average 10 minutes, including the time to review instructions, search existing data sources, gather and maintain
the data needed, and complete and review the collection of information. Comments concerning the accuracy of the time estimate and suggestions for reducing this burden
should be directed to the U.S. Department of the Treasury, Bureau of the Fiscal Service, 401 14th Street SW, Washington DC 20227.
AUTHORIZATION TO MAKE TREASURY SVC TRANSFERS ELECTRONICALLY TO AND FROM BANK OR CREDIT UNION ACCOUNT
I authorize the U.S. Treasury’s Fiscal or Financial Agent to initiate debit and credit entries to the bank or credit union account at the financial institution specified above in
order to fulfill any requests I may make to transfer funds between the bank or credit union account and this Treasury SVC account.
20. POSITION TO WHICH APPOINTED
21. SIGNATURE

22. DATE SIGNED (MMDDYYYY)

23. SIGNATURE OF COMMANDING OFFICER (may attach copy of Accountable Official’s appointment letter signed by CO in lieu of CO’s signature)

24. DATE SIGNED (MMDDYYYY)

FOR OFFICE USE ONLY
25. ISSUED BY (Disbursing/Finance Office Name/Location)
FS FORM 2888 (09-16)

26. CARD NUMBER (Last seven digits)
DEPARTMENT OF THE TREASURY
BUREAU OF THE FISCAL SERVICE