EFT INFORMATION REQUEST
1819 (2015/05)
CEC / DUNS Number +Four
Licensing Division - United States Copyright Office
TEL (202)707-8150 - FAX (202)707-0905 - www.copyright.gov/licensing
SSN / TIN
Corporations or partnerships use Federal Taxpayer Identification Number (TIN)
Independent contractors or sole proprietors use Social Security Number (SSN)
Non-Foreign firms without TIN, do not enter number
VENDOR TYPE
1. Employee 2. Federal 3. Nonfederal
TYPE OF BUSINESS
1. Small Disadvantaged Business 7. Other Nonprofit Organization 13. Federal Government - Within Bureau
2. Other Small Business 8. State/Local Government Education 14. Foreign Contractor
3. Large Business 9. State/Local Government Hospital 15. Domestic Contractor
4. Sheltered Workshop 10. Other State/Local Government 16. Woman Owned Business
5. Nonprofit Educational Organization 11. Federal Government - Non Dept. 17. Minority Owned Business
6. Nonprofit Hospital
12. Federal Government - Within Dept.
18. Emerging Small Business
Name of Business or Individual Alternate Name/Doing Business As
Primary Contact Name Telephone Number E-mail Address
Financial Contact Name Telephone Number E-mail Address
SIC CODE PRIMARY BUSINESS PRODUCT
MAILING ADDRESS
Address
City State Zip Code
Telephone Number Fax Number
REMITTANCE ADDRESS (complete only if different than the address above)
Address
City State Zip Code
Telephone Number Fax Number
ACH FINANCIAL INSTITUTION INFORMATION
Financial Institution Name Routing/ABA Number
Account Number
TYPE
Corporate Checking
Personal Checking
Lockbox
Savings
City State Zip Code Country
Account Title (if different than name of business or individual)
CERTIFICATION OF INFORMATION
I understand that the Library of Congress will make payments by ACH financial institution information.
Name Title/Position Telephone Number
Signature Date
FOR LICENSING DIVISION ONLY
Legal Name (As on statement of account)
ID# Period Type
Privacy Act Notice: Section 111, section 119 and chapter 10 of title 17, United States Code, authorizes the Copyright Office to collect the personally identifying information (PII)
requested on this form. PII is any personal information that can be used to identify or contact an individual, such as names, addresses and telephone numbers. The Copyright
Office collects this PII in order to process your refund. By providing your PII, you are agreeing to the routine use of it for this purpose. The effects of not providing the PII
requested here is that it may delay sending your refund.
