Fillable GPO - ACH Vendor/Miscellaneous Payment Enrollment Form

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GPO - ACH Vendor/Miscellaneous Payment Enrollment Form

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ACH VENDOR/MISCELLANEOUS PAYMENT
ENROLLMENT FORM
OMB No. 1510-0056
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. See reverse for additional instructions.
The following information is provided to comply with the 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.
PRIVACY ACT STATEMENT
AGENCY INFORMATION
FEDERAL PROGRAM AGENCY
AGENCY IDENTIFIER: AGENCY LOCATION CODE (ALC): ACH FORMAT:
CCD+ CTX
ADDRESS:
CONTACT PERSON NAME: TELEPHONE NUMBER:
( )
ADDITIONAL INFORMATION:
PAYEE/COMPANY INFORMATION
NAME
ADDRESS
CONTACT PERSON NAME: TELEPHONE NUMBER:
( )
SSN NO. OR TAXPAYER ID NO.
FINANCIAL INSTITUTION INFORMATION
NAME:
ADDRESS:
ACH COORDINATOR NAME: TELEPHONE NUMBER:
NINE-DIGIT ROUTING TRANSIT NUMBER:
DEPOSITOR ACCOUNT TITLE:
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:
( )
( )
SF 3881 (Rev. 2/2003 )
Prescribed by Department of Treasury
31 U S C 3322; 31 CFR 210
AUTHORIZED FOR LOCAL REPRODUCTION
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Instructions for Completing SF 3881 Form
Agency Information Section - Federal agency prints or types the name and address of the
Federal program agency originating the vendor/miscellaneous payment, agency identifier,
agency location code, contact person name and telephone number of the agency. Also, the
appropriate box for ACH format is checked.
Payee/Company Information Section - Payee prints or types the name of the payee/company
and address that will receive ACH vendor/miscellaneous payments, social security or
taxpayer ID number, and contact person name and telephone number of the payee/company.
Payee also verifies depositor account number, account title, and type of account entered by
your financial institution in the Financial Institution Information Section.
Financial Institution Information Section - Financial institution prints or types the name and
address of the payee/company's financial institution who will receive the ACH payment, ACH
coordinator name and telephone number, nine-digit routing transit number, depositor (payee/
company) account title and account number. Also, the box for type of account is checked, and
the signature, title, and telephone number of the appropriate financial institution official are
included.
1.
2.
3.
Burden Estimate Statement
The estimated average burden associated with this collection of information is 15 minutes per
respondent or recordkeeper, depending on individual circumstances. Comments concerning the
accuracy of this burden estimate and suggestions for reducing this burden should be directed to
the Financial Management Service, Facilities Management Division, Property and Supply Branch,
Room B-101, 3700 East West Highway, Hyattsville, MD 20782 and the Office of Management and
Budget, Paperwork Reduction Project (1510-0056), Washington, DC 20503.
Make three copies of form after completing. Copy 1 is the Agency Copy; copy 2 is the Payee/
Company Copy; and copy 3 is the Financial Institution Copy.
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GPO - ACH VendorMiscellaneous Payment Enrollment Form

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Completed 26 May 2020

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