Fillable AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS (Office of Financial Research)

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AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS (Office of Financial Research)

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The AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS (Office of Financial Research) form is 1 page long and contains:

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Country of origin: US
File type: PDF

U.S.A. forms for Office of Financial Research (OFR)

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The Federal government may not conduct or sponsor, and the public is not required to respond to, a collection of
information without a currently valid OMB control number. The control number for this collection is 1505-0245.
AUTHORIZATION AGREEMENT
FOR
PREAUTHORIZED
PAYMENTS
FINANCIAL RESEARCH FUND
The information requested on this form is required for the purpose of authorizing the Department of Treasury Financial Research
Fund to electronically collect semiannual assessment payments from your account. Payments will be collected July 20, 2012.
For year 2013 and years subsequent, payments will be collected March 15 and September 15. An electronic billing notification
detailing the amount of the payment will be provided via E-mail approximately 14 days prior to collection. No electronic
collection from your account may be transacted unless a signed authorization form is received. We estimate that it will take
approximately 15 minutes to complete this form. Please submit completed form to ARServiceDesk@Fiscal.Treasury.gov; please
include "FRF Assessments" in the subject line.
CHECK
ONE: START CHANGE
STOP
BANK INFORMATION
BANK NA
ME
(PLEASE
PRINT)
STREET
ADDRESS
CIT
Y/STATE:
ZIP CODE:
RSSD ID NUMBER: See Institution Search @
http://www.ffiec.gov/nicpubweb/nicweb/SearchForm.aspx
TAX PA
YER
IDENTIFICATION NUMBER
PRIMARY CONTACT
FULL
NA
ME
PRIMARY
PHONE
PRIMARY CONTACT
E-MAIL
SECONDARY
CONTACT
FULL NA
ME
SECONDARY
PHONE
SECONDARY
CONTACT E-MAIL
ADDITIONAL
CONTACT FULL
NA
ME
ADDITIONAL
PHONE
ADDITIONAL
CONTACT E-MAIL
I hereby authorize the initiation of a deduction from my account and the Department of Treasury Financial Research Fund to debit
such account. I understand I will be notified of the debit amount, and notified if the debit amount needs to be adjusted, either to be
increased or decreased. I understand that the authorization is in effect until a Change or Stop notice is initiated. I understand that I
must ensure that there are sufficient funds available in my account to perfect the assessment payment.
ACCOUNT
INFORMATION
NINE-DIGIT ROUTING TRANSIT NUMBER:
ACCOUNT TITLE
ACCOUNT NUMBER
CHECKING
SAVINGS
SIGNATURE
AND
TITLE
OF
REPRES
ENTATIVE AREA
CODE/TELEPHONE
NUMBER DATE
DEPARTMENT OF THE TREASURY
Dodd-Frank Act (Public Law 111-203)
TDF 105.1 (05/2012)
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AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS (Office of Financial Research)

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Completed 19 July 2020

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