EFTA00178604 # VENDOR ELECTRONIC FUNDS TRANSFER (EFT) ENROLLMENT FORM Please comply to this information if you have not done so already PAYEE/COMPANY INFORMATION:

Vendor Company Name:
Address:
Taxpayer ID Number
Contact Person Name
Telephone Number
E-mail Address(If you would like to be notified via e-mail)

FINANCIAL INSTITUTION INFORMATION:

Bank Name
Bank Address
Bank Phone Number
Nine Digit ABA Routing Transit Number
Type of Account(Checking or Saving)
Depositor Account Number
Signature of Vendor's Authorizing Official
Name & Title of Authorizing Official

Please Return or Fax to: U.S. Attorney's Office Southern District of Florida 99 NE 4 street, Suite 200 Miami, FL. 33132 Attention: ## Fax Number: The Debt Collection Improvement Act of 1996 requires that payments made by the Federal government, including vendor payments, must be made by electronic funds transfer (EFT). A benefit of receiving payments by EFT is that your funds are directly deposited to your account at a financial institution and are available to you on the date of payment. If you have questions regarding the delivery of the remittance information, please contact the financial institution where your account is held. If you have any questions on the completion of this form, please contact Claudia Castellanos, at FORM OBD-211 APR, 84 Page 3 of 3 |