$ $ $
Remitter’s (company) name
Contact person
Telephone number Email
Date of EFT (actual or anticipated) Type of EFT ☐ FedWire ☐ ACH
Total amount of EFT $
Legal name (See space B of Statement of Account)
Complete and email this form to licfiscal@copyright.gov or fax to (202) 707-0905 and attach a copy to the Statement(s) of Account.
: For prior and current accounting periods, the appropriate interest fee(s), if applicable, must be added to the royalty fees.
Interest rate information is available at http://www.copyright.gov/licensing/interest-rate.pdf.
5
RA- Electronic Funds Transfer
Remittance Advice for DART
Privacy Act Notice:Chapter 10 of title 17, United States Code, authorizes the Copyright Office to collect the personally identifying information (PII) requested on this form in order to process your
payment.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
identity the entities making the royalty fee payments. By providing your PII, you are agreeing to this routine use of it. The effects of not providing the PII requested are that it may delay processing of
your statement of account and it may affect the legal sufficiency ofthe filing, a determination that would be made by a court of law.
Library of Congress · U.S. Copyright Office · Licensing Division · 101 Independence Avenue SE · Washington, DC 20557-6400 · www.copyright.gov/licensing
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:
09/2018
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