Form 3881-A - Ach Vendor/miscellaneous Payment Enrollment - Hctc - 2017


Department of the Treasury - Internal Revenue Service
OMB Number
ACH Vendor/Miscellaneous Payment Enrollment -
(May 2017)
(See Instructions on Page 2)
This form is used for Automated Clearing House (ACH) payments with an addendum record that contains payment-related information
processed through the Direct Deposit Program. Recipients of these payments should bring this information to the attention of their
financial institution when presenting this form for completion.
1. Agency Information
Federal program agency
ACH format
Agency identifier
Agency Location Code (ALC)
(check one)
Contact person name
Telephone number
FAX number
2. Payee/Company Information
Annual renewal
SSN or Taxpayer ID number
Contact person name
Contact email address
Telephone number
Health Plan Provider
Telephone number
(if any)
3. Financial Institution Information
Contact at financial institution
Telephone number
Type of account
Nine-digit routing transit number
Depositor account number
General ledger
Signature of authorized official
Title of authorized official
Telephone number
Privacy Act Statement and Paperwork Reduction Act Notice
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 provisions of 31 U.S.C. 3322 and 31 CFR 210. This information will be used by the Treasury Department to transmit payment
data, by electronic means to vendor's financial institution. Failure to provide the required information may delay or prevent the receipt of payments through
the Automated Clearing House Payment System.
PAPERWORK REDUCTION ACT NOTICE. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Your
response is voluntary. You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form
displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material
in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by code section 6103. The
estimated average time to complete this form is 15 minutes. If you have comments concerning the accuracy of this time estimate or suggestions for making
this form simpler, we will be happy to hear from you. You can write to the Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution
Ave. NW, Washington, DC 20224.
Catalog Number 69576F
(Rev. 5-2017)


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