Direct Deposit Authorization Form

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DIRECT DEPOSIT AUTHORIZATION FORM
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 provision of 31 U.S.C. 3322 and 31CFR210. This information will be used by the Treasury
Department to transmit data by electronic means to the vendor’s financial institution. Failure to provide the requested
information may delay or prevent the receipt of payment through the Automated Clearing House Payment System.
I hereby authorize the U.S. Army Corps of Engineers, hereinafter called USACE to initiate direct deposit credit entries to
my (our) account indicated below and the financial institution named below, hereinafter called DEPOSITORY to credit the
same to such account.
(1) Check One of the Following Statements:
( ) ADD – Deposit my Payment to the account shown
( ) CHANGE - Financial Institutions and/or Account Number
____________________________________
(2) Installation EROC or Name of District Office
__________________________________________________________________________________________
(3)
Name or (Company as shown on Invoice) Corps of Engineers Employees (Your Name):
__________________________________________________________________________________________
(4)
Address:
__________________________________________________________________________________________
(5)
City:
State:
Zip:
__________________________________________________________________________________________
(6)
Mailing Address (if different):
__________________________________________________________________________________________
(7)
Daytime Phone:
Email:
Contract # (Optional):
If more than one contract, please list on separate sheet
Please ask your Financial Institution for your Depositor Account Number and “ACH” Routing Number
Type of Depositor Account
Checking (8)
Savings (9)
Please Check a Box
Depositor Account Number (10)
________________________________________________________________________________________
(11)
Name of Financial Institution:
________________________________________________________________________________________
(12)
Address:
________________________________________________________________________________________
(13)
City:
State:
Zip:
________________________________________________________________________________________
(14)
Routing Number:
________________________________________________________________________________________
(15)
Depositor Account Title:
Tax ID Number (TIN) for Business or
SSN for Individuals (16)
SIGNATURE: (
) _______________________________________ DATE: (
) _____________________
17
18
Mail to:
You may fax your document directly to
USACE Finance Center
the Corps of Engineers Finance Center
ATTN EFT/Disbursing
Disbursing Office at:
5722 Integrity Drive
Millington TN 38054-5005
901-874-8572 or 901-874-8574
UFC-DISB-4

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