Local Assistance and Tribal Consistency Fund Recipient P

OMB Approved No. 1505-0276

Expiration Date: MM/DD/YYYY

Local Assistance and Tribal Consistency Fund

Recipient Payment Information Form

PAYMENT INFORMATION

Recipient Name
Recipient’s Taxpayer ID Number
Recipient’s Unique Entity Identifier (UEI)
Recipient’s Address
Street
City
State
Postal Code
Name of Authorized Representative for the Recipient*
Title of Authorized Representative for the Recipient
Authorized Representative Email
* The Authorized Representative is the individual with legal authority to bind the Recipient or the Chief Executive Officer of the Recipient. The Authorized Representative will also complete certifications and assurances on behalf of the Recipient.
Contact Person Name
Contact Person Title
Contact Person Phone
Contact Person E-mail

RECIPIENT TYPE

Type of Recipient (choose one):

Eligible Revenue Sharing County (including the District of Columbia, the Commonwealth of Puerto Rico, Guam, and the United States Virgin Islands)

Eligible Tribal Government

FINANCIAL INSTITUTION INFORMATION

Routing Transit Number (WIRE) (Optional)
Routing Transit Number (ACH)
Recipient’s Account Number
Financial Institution Name
Financial Institution Address
Street
City
State
Postal Code
Financial Institution Telephone Number

PAPERWORK REDUCTION ACT NOTICE

The information collected will be used for the U.S. Government to process requests for support. The estimated burden associated with this collection of information is one hour per response. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Office of Privacy, Transparency and Records, Department of the Treasury, 1500 Pennsylvania Ave., N.W., Washington, D.C. 20220. DO NOT send the form to this address. 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 control number assigned by OMB.