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<br />ACH VENDOR/MISCELLANEOUS PAYMENT <br />ENROLLMENT FORM <br /> <br />OMB No. 1510-0056 <br />Expiration Date 01/31/2000 <br /> <br />This form is used for Automated Clearing House (ACH) payments with an addendum record that contains <br />payment-related information processed through the Vendor Express Program. Recipients of these <br />payments should bring this information to the attention of their financial institution when presenting this <br />form for completion. <br /> <br />PRIVACY ACT STATEMENT <br /> <br />The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). All <br />information collected on this form is required under the provisions of 31 U.S.C. 3322 and 31 CFR <br />210. This information will be used by the Treasury Department to transmit payment data, by <br />electronic means to vendor's financial institution. Failure to provide the requested information may <br />delay or prevent the receipt of payments through the Automated Clearing House Payment System. <br /> <br />, <br /> AGENCY INFORMATION <br />FEDERAL PROGRAM AGENCY BUREAU OF ALCOHOL. TOBACCO AND FIREARMS <br />AGENCY IDENTIFIER: 303 IAGENCY LOCATION CODE (ALC): 20-10-0001 I ACH FORMAT: <br /> n CCD+ 0 CTX DCTP <br />ADDRESS: PO BOX 51071, WASHINGTON, DC 20091-1071 <br />CONTACT PERSON NAME: WilliAM T. WRIGHT 1(202)927-7725 T. <br />ADDITIONAL INFORMATION: <br /> <br />PAYEE/COMPANY INFORMATION <br />NAME ISSN NO. OR TAXPAYER 10 NO. <br />ADDRESS <br />CONTACT PERSON NAME: ITELEPHONE NUMBER: <br /> ( ) <br /> <br />FINANCIAL INSTITUTION INFORMATION <br />NAME: <br />ADDRESS: <br />ACH COORDINATOR NAME: TELEPHONE NUMBER: <br /> ( ) <br />NINE.DIGIT ROUTING TAANSIT NUMBER: <br />- - --- --- - <br />DEPOSITOR ACCOUNT TITLE: <br />DEPOSITOR ACCOUNT NUMBER: ILOCKBOX NUMBER: <br />TYPE OF ACCOUNT: <br />D CHECKING o SAVINGS o LOCKBOX <br />SIGNATURE AND TITLE OF AUTHORIZED OFFICIAL: TELEPHONE NUMBER: <br />(Could be the I_a as ACH Coordinator) <br /> ( ) <br /> ~I' alllll IHav l;tII:lUI <br /> <br />.. <br />" <br /> <br />NSN 7540.01.274.9925 <br /> <br />AGENCY COPY <br /> <br />Prelcribed by Depertmant of Treasury <br />31 US C 3322; 31 CFR 210 <br />