Ach Form - International Terrorism Victim Expense Reimbursement Program - Office For Victims Of Crime - U.s. Department Of Justice

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U.S. Department of Justice
Office of Justice Programs
Office for Victims of Crime
INTERNATIONAL TERRORISM VICTIM EXPENSE REIMBURSEMENT PROGRAM
ACH FORM – Required for Payment
TO BE COMPLETED BY THE OFFICE FOR VICTIMS OF CRIME
DATE:
CLAIM/INVOICE #:
VICTIM NAME:
CLAIMANT NAME:
VICTIM ID:
CLAIMANT ID/VENDOR #:
AMOUNT TO BE PAID:
TO BE COMPLETED BY CLAIMANT
PAYEE NAME
RELATIONSHIP TO VICTIM
Contact Information:
MAILING ADDRESS
TELEPHONE
FAX
EMAIL
OTHER
For EFT (Electronic Funds Transfer) Payments (required):
PAYEE/VENDOR NAME
FULL BANK NAME
BANK ROUTING NUMBER
ACCOUNT NUMBER
ACCOUNT TYPE
Checking
Savings
For Check Payments (Please note: This option is only available for overseas payments without EFT access):
MAILING ADDRESS
PREFERRED METHOD OF DELIVERY
(If different from above)

USPS
Courier
__________________
Nearest Embassy:
__________________
Other:

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