PAYMENT INFORMATION FORM ACH VENDOR PAYMENT SYSTEM
PAYMENT INFORMATION FORM
ACH VENDOR PAYMENT SYSTEM
This form is used for the ACH payments with an addendum record that carries payment-related information. Recipients of these
payments should bring this information to the attention of their financial institution when presenting this form for completion.
PAPERWORK REDUCTION ACT STATEMENT
The information being collected on this form is required under the provision 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 Clearinghouse Payment System.
MEDICAL PROVIDER INFORMATION
OWCP Provider ID
Name
Address
Contact Person Name
Telephone Number
AGENCY INFORMATION
Name: U.S. Department of Labor-Office of Workers¡¯ Compensation Program
Address:
Provider Enrollment
P.O. Box 34690, San Antonio, TX 78265
Contact Person Name:
Telephone Number:
FINANCIAL INSTITUTION INFORMATION
Name
Street Address
City
State
ACH Coordinator Name
Select
Zip Code
Telephone Number
Nine-Digit Routing Transit Number
Depositor Account Title
Depositor Account Number
Type of Account
Checking
Signature and Title of Representative
SF Form
m
3881
Savings
Telephone Number
Department of the Treasury Financial
Management Service
................
................
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