U.S. Department of Justice Office of Justice Programs Office for Victims of Crime
INTERNATIONAL TERRORISM VICTIM EXPENSE REIMBURSEMENT PROGRAM
ACH FORM – Required for Payment
TO BE COMPLETED BY THE OFFICE FOR VICTIMS OF CRIME
DATE: CLAIM/INVOICE #:
VICTIM NAME: CLAIMANT NAME:
VICTIM ID: CLAIMANT ID/VENDOR #:
AMOUNT TO BE PAID:
TO BE COMPLETED BY CLAIMANT
PAYEE NAME RELATIONSHIP TO VICTIM
Contact Information:
MAILING ADDRESS TELEPHONE
FAX
EMAIL
OTHER
For EFT (Electronic Funds Transfer) Payments (required):
PAYEE/VENDOR NAME
FULL BANK NAME
BANK ROUTING NUMBER
ACCOUNT NUMBER
ACCOUNT TYPE
Checking Savings
For Check Payments (Please note: This option is only available for overseas payments without EFT access):
MAILING ADDRESS
(If different from above)
PREFERRED METHOD OF DELIVERY
USPS Courier
Nearest Embassy:
__________________
Other: __________________
