ACH FEDERAL 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.

PRIVACY ACT STATEMENT

 

The following information is provided to comply with th 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

FEDRAL PROGRAM AGENCY

     

AGENCY IDENTIFIER:

     

AGENCY LOCATION CODE (ALC):

     

ACH FORMAT:

 CCD+              CTX             CTP

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:

Bank of America

ADDRESS:

     

 

     

ACH COORDINATOR NAME:

     

TELEPHONE NUMBER:

(     )      

NINE-DIGIT ROUTING TRANSIT NUMBER:

0    6    3    1    0    0     2    7    7_

DEPOSITOR ACCOUNT TITLE:

Chief Financial Office of Florida

DEPOSITOR ACCOUNT NUMBER:

     

LOCKBOX NUMBER:

     

TYPE OF ACCOUNT:

 CHECKING             SAVINGS             LOCKBOX

SIGNATURE AND TITLE OF AUTHORIZED OFFICIAL:

(Could be the same as ACH Coordinator)

 

TELEPHONE NUMBER:

 

(     )