Form 28 Electronic Transfer of Funds (ETF) Authorization

Entity: TEST ENTITY (FAIRFAX, VA) | User: administrator

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EFT AUTHORIZATION

Complete this form to authorize payment of user fees directly from your bank account. Limit your responses
to the number of characters, including spaces and punctuation, specified in parentheses for each field.
OMB # 0915-0239 expiration date 05/31/14
OMB # 0915-0126 expiration date 12/31/13
OMB # 0915-0331 expiration date 12/31/13
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond
to, a collection of information unless it displays a currently valid OMB control number. The OMB control
numbers for this project are 0915-0239, 0915-0126 and 0915-0331. Public reporting burden for this
collection of information is estimated to average 15 minutes to complete this form, including the time for
reviewing instructions, searching existing data sources, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600
Fishers Lane, Room 14-22, Rockville, Maryland, 20857.
ACCOUNT INFORMATION
Bank Routing Number (9 digits):
Bank Account Number (max 17 digits):
Bank Account Type:

 Checking




 Savings





Bank routing information can be found on your check. See picture below.

CERTIFICATION

Name of Certifying Official:
Title of Certifying Official:
Telephone:
Certification Date (MMDDYYYY):

Ext.
11302012

Submit to Data Bank

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