Fillable PRIVACY ACT STATEMENT AUTHORITY: 5 USC 5701,37 USC (Air Force Institute of Technology)

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PRIVACY ACT STATEMENT AUTHORITY: 5 USC 5701,37 USC (Air Force Institute of Technology)

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PRIVACY ACT STATEMENT
AUTHORITY: 5 USC 5701,37 USC 404427, and EO 9397. PRINCIPAL PURPOSE(S): Used for
reviewing approving. accounting and disbursing. SSN is used to maintain a numerical identification
system for Individual claims.
ROUTINE USE(S): To substantiate claims for reimbursement.
DISCLOSURE: Voluntary, however, failure to furnish information requested may result in total or
partial denial of amount claimed.
EFT AUTHORIZATION
AUTHORIZATION TO ESTABLISH ELECTRONIC FUNDS TRANSFER (EFT)
FOR REIMBURSEMENT PAYMENT
I request my Reimbursement payment be sent via EFT to my Direct Deposit account and authorize the
required information be extracted from my Pay Records. I understand if I change my Pay Account I am
required to notify the Program Manager of this change. Additionally, I understand I need to verify the funds
are deposited into my account prior to withdrawing funds against the amount paid.
________________________
Date
________________________ _________________________
Printed Name SSAN
________________________
Organization and Duty Phone
(MARK ONE) I am a Civilian Employee _____ Military Member ______
Home Address: ________________________________________
________________________________________
________________________________________
___________________________________
Signature
-----------------------------------------------------------------------------------------------------------------------------
ACCOUNT NUMBER ____________________________________
ROUTING NUMBER ____________________________________
TYPE OF ACCOUNT: CHECKING ______ SAVINGS ________
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PRIVACY ACT STATEMENT AUTHORITY: 5 USC 5701,37 USC (Air Force Institute of Technology)

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Completed 27 September 2021

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