EFTA00186802¶
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: Jocelyn Collazo¶
Fax Number: 305-530-7679¶
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 305-961-9254.¶
FORM OBD-211 APR. 84 Page 3 of 3¶
EFTA00186803¶