Fillable Smithsonian Institution Vendor Enrollment (Harvard University)

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Smithsonian Institution Vendor Enrollment (Harvard University)

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Smithsonian Institution Vendor Enrollment
Vendor Action Create NEW ___ Change Existing Vendor # _________________
Vendor Type
(Check One)
Supplier ___ Other Government Agency ___ Stipend Recipient ___ No Fee Consultant ___
Vendor Name
TIN/ITIN
or SSN
__ __ __ __ __ __ __ __ __
Short Name
(May be changed by OC)
DUNS # __ __ __ __ __ __ __ __ __
REMIT TO ADDRESS (for check disbursements ONLY).
NOTE to Vendor: check disbursement may delay receipt of payment.
Remit To Address
City State Zip
Contact Name Phone
Email FAX
Buy From Address
Buy From Address
City State Zip
Contact Name Phone
Email FAX
Business Mailing Address
Business Address
City State Zip
Contact Name Phone
Email FAX
Business Type (check all that apply)
8(a) Program Participant Construction Firm Municipality
American Indian Owned Educational Institution Nonprofit Organization
HUB Zone Firm (*See note below) Emerging Small Business Research Institution
Minority Owned Business Foreign Supplier S Corporation
Large Business Historically Black College/Univ Service Location
Small Business Labor Surplus Area Firm Sheltered Workshop (JWOD Supplier)
Small Disadvantaged Business Limited Liability Company Tribal Government
Woman Owned Business Manufacturer of Goods Hospital
Veteran Owned Business Minority Institution
Service Disabled Veteran Owned
(*Note: HUB Zone Firm is a Historically Underutilized Business Zone Firm.)
Minority Owned Business Specific Types (check one)
Subcontinent Asian (Asian-Indian)
American Owned
Asian-Pacific American Owned Black American Owned
Hispanic American Owned Native American Owned No Representation/None of the Above
TAX and Withholding Information (check one)
1099 Recipient Y N 1042 Recipient Y N
1099 Code (check one) Rents Royalties Prizes and Awards Health Care Non-employee Compensation
Federal Taxes will be withheld for Vendors without TIN/ITINS doing business in the U.S.
Withholding Tax Rate Exempt Code Country Code
REQUIRED
Vendor Authorized
Signer Name
Phone
Title
Vendor Signature
X___________________________________________________
SMITHSONIAN INSTITUTION USE ONLY
SI Unit Contact Name:
DEPT
ID
__ __ __ __ __ __ Phone
Special Instructions to OC
Attachment 1 - 07-003 (# 06)
SMITHSONIAN INSTITUTION
ENROLLMENT FORM
ACH VENDOR/MISCELLANEOUS PAYMENT
SI-3881-E- REV. 9/02
This form is used for Automated Clearing House (ACH) payments with an addendum record that contains pay-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.
PAYEE/COMPANY INFORMATION
NAME: SSN NO. OR TAX PAYER ID. NO:
ADDRESS:
CONTACT PERSON NAME: TELEPHONE NUMBER:
FINANCIAL INSTITUTION INFORMATION
NAME:
ADDRESS:
ACH COORDINATOR NAME: TELEPHONE NUMBER:
NINE DIGIT ROUTING TRANSIT NUMBER:
___ ___ ___ ___ ___ ___ ___ ___ ___
DEPOSITOR ACCOUNT TITLE:
DEPOSITOR ACCOUNT NUMBER:
TYPE OF ACCOUNT:
CHECKING SAVINGS
SIGNATURE AND TITLE OF AUTHORIZED OFFICAL: TELEPHONE NUMBER:
AGENCY INFORMATION
FEDERAL PROGRAM AGENCY:
SMITHSONIAN INSTITUTION
AGENCY LOCATION CODE (ALC):
33010001
ACH FORMAT:
CCD+ _____ PPD + _____
AGENCY IDENTIFIER:
SI
ADDRESS: Smithsonian Astrophysical Observatory
Subcontracts and Procurement
60 Garden Street, Mail Stop 22
Cambridge, MA 02138-1516
CONTACT PERSON NAME:
Mr. Joseph Lendall
FAX NUMBER:
617-496-7957
TELEPHONE NO:
617-495-7401
UNIT CONTACT PERSON: FAX NUMBER: TELEPHONE NO:
PRIVACY ACT STATEMENT
The above 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 date, 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.
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Smithsonian Institution Vendor Enrollment (Harvard University)

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Completed 21 December 2020

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