Catalog Number 69576F www.irs.gov
Form
3881-A (Rev. 5-2017)
Form 3881-A
(May 2017)
Department of the Treasury - Internal Revenue Service
ACH Vendor/Miscellaneous Payment Enrollment -
HCTC
OMB Number
1510-0056
(See Instructions on Page 2)
This form is used for Automated Clearing House (ACH) payments with an addendum record that contains payment-related information
processed through the Direct Deposit Program. Recipients of these payments should bring this information to the attention of their
financial institution when presenting this form for completion.
1. Agency Information
Federal program agency
Agency identifier Agency Location Code (ALC)
ACH format (check one)
CCD+ CTX
Address
Contact person name
Telephone number
FAX number
2. Payee/Company Information
New Annual renewal
Name SSN or Taxpayer ID number
Address
Contact person name Contact email address Telephone number
Health Plan Provider (if any) Telephone number
3. Financial Institution Information
Name
Address (optional)
Contact at financial institution (optional) Telephone number
Nine-digit routing transit number Depositor account number
Type of account
Checking Savings General ledger
Signature of authorized official Title of authorized official Telephone number
Privacy Act Statement and Paperwork Reduction Act Notice
PRIVACY ACT STATEMENT. 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 required information may delay or prevent the receipt of payments through
the Automated Clearing House Payment System.
PAPERWORK REDUCTION ACT NOTICE. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Your
response is voluntary. You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form
displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material
in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by code section 6103. The
estimated average time to complete this form is 15 minutes. If you have comments concerning the accuracy of this time estimate or suggestions for making
this form simpler, we will be happy to hear from you. You can write to the Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution
Ave. NW, Washington, DC 20224.
Page 2
Catalog Number 69576F www.irs.gov
Form
3881-A (Rev. 5-2017)
Instructions for Form 3881-A, ACH Vendor/Miscellaneous Payment Enrollment - HCTC
Internal Revenue Service to establish Automated Clearing House (ACH) payments, also referred to as Electronic Funds Transfers (EFTs).
1. Agency Information Section – Contains 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 and the ACH format.
2. Payee/Company Information Section – Print or type the name of the payee/Health Plan Adminstrator (HPA)and address that will
manage ACH vendor/miscellaneous payments, social security or taxpayer ID number (may also be referred to as the employer
identification number), contact person and telephone number of the payee/company. Payee also verifies depositor account number and
type of account entered by your financial institution in the Financial Institution Information Section. If necessary, print or type the name of
any third party health care company used by the HPA.
3. Financial Institution Information Section – Print or type the name and address of the payee/company's financial institution that will
receive the ACH payment, ACH coordinator name and telephone number, nine-digit routing transit number, depositor (payee/company)
account number and type of account. Signature, title, and telephone number of the appropriate financial institution official is included.
Note: If the designated Payee/Company contact person knows all of the requested bank information, the Payee/Company contact may
complete the Financial Institution Information Section. There is no requirement for a bank official signature.
Burden Estimate Statement
The estimated average burden associated with this collection of information is 15 minutes per respondent or record keeper, depending on
individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be
directed to the Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave., NW, Washington, DC 20224 or the
Office of Management and Budget, Paperwork Reduction Project (1510-0056), Washington, DC 20503.
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