Form 1 ACH Vendor Payment Form

OMB No. 1510-0056

ACH VENDOR/MISCELLANEOUS PAYMENT
ENROLLMENT FORM

This form is used for Automated Clearing House (ACH) payments with an addendum record that contains
payment-related information processed through the Vendor Express Program. Recipients of these
payments should bring this information to the attention of their financial institution when presenting this
form for completion. See reverse for additional instructions.
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 requested information may
delay or prevent the receipt of payments through the Automated Clearing House Payment System.
AGENCY INFORMATION

FEDERAL PROGRAM AGENCY

National Institutes of Health, Office of Financial Management
AGENCY IDENTIFIER:

NIH Treasury 303

AGENCY LOCATION CODE (ALC):

ACH FORMAT:

75-08-0031

CCD+

CTX

ADDRESS:

2115 East Jefferson Street, MSC 8500, Suite 4B-432, Bethesda, MD 20892-8500
(For FedEx, UPS, and other courier services, use Rockville, MD 20852)
CONTACT PERSON NAME:

TELEPHONE NUMBER:

( 301

Ratna Bhadra
ADDITIONAL INFORMATION:

) 435-3505; Fax: 301-402-4684

Fellowship ACH forms should be faxed to 301-402-1025.

PAYEE/COMPANY INFORMATION

NAME

SSN NO. OR TAXPAYER ID NO.

ADDRESS

CONTACT PERSON NAME:

TELEPHONE NUMBER:

(

NAME:

)

FINANCIAL INSTITUTION INFORMATION

ADDRESS:

ACH COORDINATOR NAME:

TELEPHONE NUMBER:

(

NINE-DIGIT ROUTING TRANSIT NUMBER:

)

DEPOSITOR ACCOUNT TITLE:
DEPOSITOR ACCOUNT NUMBER:

LOCKBOX NUMBER:

TYPE OF ACCOUNT:
CHECKING
SIGNATURE AND TITLE OF AUTHORIZED OFFICIAL:
(Could be the same as ACH Coordinator)

SAVINGS

LOCKBOX
TELEPHONE NUMBER:

(
AUTHORIZED FOR LOCAL REPRODUCTION

)

SF 3881 (Rev. 2/2003 )
Prescribed by Department of Treasury
31 U S C 3322; 31 CFR 210

Instructions for Completing SF 3881 Form
Make three copies of form after completing. Copy 1 is the Agency Copy; copy 2 is the
Payee/Company Copy; and copy 3 is the Financial Institution Copy.

1.

Agency Information Section - Federal agency prints or types 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. Also, the appropriate box for ACH format is checked.

2.

Payee/Company Information Section - Payee prints or types the name of the
payee/company and address that will receive ACH vendor/miscellaneous payments,
social security or taxpayer ID number, and contact person name and telephone number
of the payee/company. Payee also verifies depositor account number, account title, and
type of account entered by your financial institution in the Financial Institution
Information Section.

3.

Financial Institution Information Section - Financial institution prints or types the name
and address of the payee/company's financial institution who will receive the ACH
payment, ACH coordinator name and telephone number, nine-digit routing transit
number, depositor (payee/company) account title and account number. Also, the box
for type of account is checked, and the signature, title, and telephone number of the
appropriate financial institution official are included.

Burden Estimate Statement
The estimated average burden associated with this collection of information is 15 minutes
per respondent or recordkeeper, depending on individual circumstances.
Comments
concerning the accuracy of this burden estimate and suggestions for reducing this burden
should be directed to the Financial Management Service, Facilities Management Division,
Property and Supply Branch, Room B-101, 3700 East West Highway, Hyattsville, MD
20782 and the Office of Management and Budget, Paperwork Reduction Project
(1510-0056), Washington, DC 20503.