EFTA00186197¶
U.S. Department of Justice Washington, D.C. 20530¶
Request for Financial Information (Authorization, Purchase Order, Receiving Report)¶
This form shall only be used when reporting financial records of individuals and partnerships of five or fewer individuals.¶
1 Purchase Order Number/DCNF 11011 - 1960¶
2 Date Order Prepared: 08/02/2006¶
3 Cause Number: (Optional) FGJ 05-02(WPB) NO.051-01 (OLY-01)¶
Section A - Authorization and Purchase Order¶
4 Names and Addresses of Financial Institution: Attn.: Anita Muller, Research Dent Colonial Bank, Loover, AL 35243 - Fax:¶
5 Deliver To: Special Agent Suite 500, Florida 33401, Tel.: 412-789-1234¶
6 Return Date 08/18/2006¶
7 Remarks: FOR REIMBURSEMENT PLEASE RETURN THIS FORM, THE RECORD OF SERVICES, AND A COPY OF THE SUBPOENA.¶
8 Name of Requestor: (Type or Print) Villafaña, AUSA¶
9 Telephone Number: 08/02/2006¶
Section B - Financial Institution Invoice¶
No Payment Shall Be Made Unless Expenses Are Imitated Below Or On Your Form To Be Attached.¶
11 Service/Financial Records Provided:¶
| Quantity | Unit Price | Amount |
|---|---|---|
| Cost | Per | |
| Please note that reimbursement cannot be made for the records pertaining to corporations or large partnerships of six or more. IMPORTANT: The DCIA Mandates the use of EFT/DD. In order to receive payment complete the attached EFT enrollment Form. | 0.25 | Copy |
| 11.00 | Hour Clerical Tech | |
| 17.00 | Hour Manager or Supervisor |
Do not proceed with compliance: If cost will exceed $300 without prior approval of Assistant U.S. Attorney/Budget Officer. Please reference THE MOVE.DCNR ON YOUR INVOICE FOR PAYMENT.¶
12a Signature of Financial Institution Official: 12b Phone of Financial Institution Official: 13 Date Signed: Total Amount Claimed By Financial Institution¶
Section C - Receiving Report¶
14 I certify that the articles and services listed were received:¶
15 Date Received: 17 Net to Financial Institution¶
18 Right to Financial Privacy Act - Public Law 95-630 (12 U.S.C. 3401-3422) Request Pursuant To: (Check One Only) SECTION OBJECT CLASS¶
□ 3404 Customer Authorization □ 3405 Administrative Subpoena or Summons □ 3406 Search Warrant □ 3407 Judicial Subpoena □ 3408 Formal Written Request □ 3413 I Grand Jury Subpoena □ 3414 Special Procedures¶
19 Signature of Approval Official:¶
20 Accounting Classification Code¶
FY PG 1 2 3 4 5 PROJ¶
21 Schedule and Voucher Number: DC#¶
22 Remarks:¶
☐ Funds Available¶
Date Budget Officer¶
Form OBD211 APR 84¶
EFTA00186198¶
GENERAL¶
This is a multi-purpose form designed to serve as an Authorization, Purchase Order, Itemized Invoice, receiving Report and Payment voucher in conjunction with “requests for financial information,” pursuant to the Right to Financial Privacy Act of 1978, P.L. 95-630, Title XL, 12 U.S.C. 3415.¶
NOTE:¶
Payments under this purchase order will be due on the 30th calendar day after the date of actual receipt of a proper invoice in the office designated to receive the invoice.¶
The Prompt Payment Act, Public Law 97-177, 96 Stat. 85 (31 U.S.C. 180), is applicable to payments under this purchase order and requires the payment to contractors of interest or overdue payments and improperly taken discounts. Determination of interest due will be made in accordance with the provision of the Prompt Payment Act and the Office of Management and Budge Circular A-125.¶
PREPARATION INSTRUCTIONS¶
ITEM 1 - A Purchase Order Number will be preprinted on each form. This number will be used for reference purposes on any correspondence relating to this specific request for financial information.¶
ITEM 2 - Self explanatory.¶
ITEM 3 - This block may be used to identify the specific case for which the financial information is required. This block may be left blank.¶
SECTION A - AUTHORIZATION AND PURCHASE ORDER (To be completed by the requesting official).¶
ITEM 4 - Enter the name and mailing address of the financial institution being requested to furnish financial information.¶
ITEM 5 - Enter the and address to which the financial information is to be sent by the financial institution. This will normally be the name and the address of the requesting official.¶
ITEM 6 - Enter the date the financial information is required.¶
ITEM 7 - Include, if appropriate, any pertinent information related to the purchase order not provided for elsewhere on the form¶
ITEM 8, 9 and 10 - Self-explanatory.¶
SECTION B - FINANCIAL INSTITUTION INVOICE (To be completed by the financial institution).¶
ITEM 11 - Self-explanatory. Completion of this block constitutes an itemized bill or invoice for reimbursement for the costs incurred in providing the information requested. The DCIA Mandates the use of EFT/DD. In order to receive payment complete the attached EFT enrollment Form.¶
ITEM 12 and 13 - Self-explanatory.¶
SECTION C - RECEIVING REPORT (To be completed by the requesting official, when the requested financial information has been delivered).¶
ITEM 14 and 15 - Self-explanatory.¶
ITEM 16 - This block should be used to reflect any differences between the amount claimed by the financial institution and the correct amount to be reimbursed. Differences may result from computation errors, or failure of the financial institution to deliver information requested.¶
ITEM 17 - Enter the amount certified to be proper for payment.¶
ITEM 18 - Check the box which identifies the appropriate procedure authorized by the Act, which necessitates the request for financial information.¶
ITEM 19 and 20 - These blocks must be signed and dated by an official of the organization whose funds will be charged. His or her signature constitutes a statement that the records to which the invoice refers were required for official business and were provided by the financial institution in accordance with the ordering instrument.¶
ITEM 21 - The Schedule and Voucher Number will be entered by the office which actually schedules the approved amount for payment by the Treasury Department.¶
ITEM 22 - Enter, if appropriate, any data not provided for elsewhere on the reeiving report, such as, reasons for any claim amounts disallowed.¶
FORM OBD-211 APR. 84 Page 2 of 3¶
EFTA00186199¶
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¶
at 305-961-9254.¶
FORM OBD-211 APR. 84 Page 3 of 3¶