Laserfiche WebLink
ACH VENDOR/MISCEI.LANEOUS PAYMENT OMBNO.1510.0058 <br />Exqredon Data 01131I2000 <br />ENROLLMENTFORM <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. R6cipients of these <br />payments should bring this information to the attention of their financial institution when presenting this <br />fnrm fnr r.nm[flBtlOfl. <br />PRIVACY ACT STATEMENT <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 />AGENCY INFORMATION <br />FEDERAL PflOGHAM AGENCY BUREAU OF ALCOHOL, TOBACCO AND FIREAflMS <br />AGENCY IDENTIFIEfl: 303 <br />AGENCV LOCATION CODE (ALCI: 20-10.0001 <br />F-I <br />ACH FORMAT: <br />CCD LTX CTP <br />ADDRE55: PO BOX 61071. WASHINGTON, DC 20091-1071 <br />CONTACT PERSON NAME: WILLJAM T. WHIGHT <br />T. <br />T <br />(202)927-7726 <br />ADDITIONAL INFOflMATION: <br />. <br />FINANCIAL INSTITUTION INFORMATION <br />NAME: <br />ADDflESS: <br />' <br />TELEPHONE NUMBER: <br />ACH COOPOINATOfl NAME: <br />( I <br />NINE-DIGIT ftOUTING TflANS1T NUMBER: <br />DEPOSITOR ACCOUNT TITLE: <br />LOCKBOX NUMBER: <br />DEPOSITOR ACCOUNT NUMBER: <br />TYPE OF ACCOUM: <br />CHECKING SAVINGS LOCKBOX <br />TELEPHONENUMBEN: <br />StGNATUPE AND 71TLE OF AU7HOflIZEO OFFICIAL: <br />lCoWd bs Nw sune aa ACH Caordinetorl <br />av <br />_r r....rv <br />NSN 7640-01•274-9925 AGENCY COPY Fla~W-., <br />31 U S C 3322: 31 CFfl 210 <br />