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ACH VENDOR/MISCELLANEOUS PAYMENT OMB No. 1510-0056 <br /> ENROLLMENT FORM <br /> This form is used for Automated Clearing House (ACH) payments with an addendum record that contains <br /> payment-related information processed through the Vendor Express Program. Recipients of these <br /> j payments should bring this information to the attention of their financial institution when presenting this <br /> form for completion. <br /> PRIVACY ACT STATEMENT <br /> <br /> i <br /> The following information is provided to comply with the Privacy Act of 1974 (P. L. 93-579). All <br /> information collected on this form is required under the provisions of 31 U.S.C. 3322 and 31 CFR <br /> 210. This information will be used by the Treasury Department to transmit payment data, by <br /> electronic means to vendor's financial institution. Failure to provide the requested information may <br /> delay or prevent the receipt of payments through the Automated Clearing House Payment System. <br /> AGENCY INFORMATION <br /> FEDERAL PROGRAM AGENCY <br /> AGENCY IDENTIFIER: ~ AGENCY LOCATION CODE ALC : ACH FORMAT: <br /> CCD+ ? CTX CTP <br /> ADDRESS: <br /> CONTACT PERSON NAME: TELEPHONE NUMBER: <br /> ADDITIONAL INFORMATION: <br /> PAYEE/COMPANY INFORMATION <br /> NAME SSN NO. OR TAXPAYER ID NO. <br /> CITY OF EUGENE _ FINANCIAL SERVICES 93-6002160 <br /> ADDRESS <br /> PO BOX 1967 <br /> EUGENE OREGON 9 7 4.4..0 <br /> CONTACT PERSON NAME: TELEPHONE NUMBER: <br /> -SUE CUTSOGEORGE 'T'REASURER - - - (541 ) 682 5589 - <br /> FINANCIAL INSTITUTION INFORMATION <br /> NAME <br /> - <br /> ADDRESS: <br /> ~®o ~ <br /> ~ 7~ ? <br /> ACH COORDINATOR N E: TELEPHONE NUMBER: <br /> (S ) S " Q9 <br /> _NINE-DIGIT. ROUTING TRANSIT NUMBER: ~ n ~ O O O <br /> DEPOSITOR. ACCOUNT. TITLE:.... ~L <br /> r _ G <br /> DEPOSITOR ACCOUNT NUMBER: LOCKBOX NUMBER: <br /> ao 3 ~lov <br /> TYPE OF ACCOUNT: <br /> CKING SAVINGS LOCKBOX , <br /> SIGNATURE AND TITLE OF HORIZED OFFICIAL: TELEPHONE NUMBER: <br /> ICould be the s e CH Co dinator) <br /> s- <br /> NSN 7540-01-274-9925 ev <br /> Prescribed by Department of Treasury <br /> 31 U S C 3322; 31 CFR 210 <br /> <br />