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

Page 2

Instructions for Form 3881-A, ACH Vendor/Miscellaneous Payment Enrollment - HCTC

Internal Revenue Service to establish Automated Clearing House (ACH) payments, also referred to as Electronic Funds Transfers (EFTs).

1. Agency Information Section – Contains the name and address of the Federal program agency originating the vendor/miscellaneous

payment, agency identifier, agency location code, contact person name and telephone number of the agency and the ACH format.

2. Payee/Company Information Section – Print or type the name of the payee/Health Plan Adminstrator (HPA)and address that will

manage ACH vendor/miscellaneous payments, social security or taxpayer ID number (may also be referred to as the employer

identification number), contact person and telephone number of the payee/company. Payee also verifies depositor account number and

type of account entered by your financial institution in the Financial Institution Information Section. If necessary, print or type the name of

any third party health care company used by the HPA.

3. Financial Institution Information Section – Print or type the name and address of the payee/company's financial institution that will

receive the ACH payment, ACH coordinator name and telephone number, nine-digit routing transit number, depositor (payee/company)

account number and type of account. Signature, title, and telephone number of the appropriate financial institution official is included.

Note: If the designated Payee/Company contact person knows all of the requested bank information, the Payee/Company contact may

complete the Financial Institution Information Section. There is no requirement for a bank official signature.

Burden Estimate Statement

The estimated average burden associated with this collection of information is 15 minutes per respondent or record keeper, depending on

individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be

directed to the Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave., NW, Washington, DC 20224 or the

Office of Management and Budget, Paperwork Reduction Project (1510-0056), Washington, DC 20503.

3881-A

Catalog Number 69576F

Form

(Rev. 5-2017)

Form 3881-A - Ach Vendor/miscellaneous Payment Enrollment - Hctc - 2017 Page 2