Rd 1951-65

RD Form 1951-65
(10-03)

Form Approved
OMB No. 0575-0184
U.S. Department of Agriculture
Rural Development
St. Louis, Missouri

Customer Initiated Payments ( CIP )
Enrollment Form
Please process my request pertaining to the Customer Initiated Payments (CIP) program which uses the Automated Clearing House (ACH)
to pay my Rural Utilities Service loan. I understand that the CIP/ACH payments will only be made for my organization on the date that I
authorize from the contact our organization makes with the CIP provider.

Current date :

__ __ / __ __ / __ __ __ __

Action Requested:

Add

Change

Delete

MASTER FILE CIP DATA
Reference No.:

____ ____ - ____ ____ ____ (last 5 or 6 digits as shown on RUS Form 615)

Borrower Name:

_____________________________________________________________

Address:

_____________________________________________________________

City/State/Zip:

________________________________________, ___ ___ __ __ __ __ __

Contact Person/Title:

______________________________________________ (Please Print)

Signature of Contact:

______________________________________________ (Signature Only)

Telephone No.:

___ ___ ___ -- ___ ___ ___ -- ___ ___ ___ ___

Fax No.:

___ ___ ___ -- ___ ___ ___ -- ___ ___ ___ ___

Routing Transit No.:

___ ___ ___ ___ ___ ___ ___ ___ ___ (Must be 9 Digits)

Account No.:

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Acct. Type:
Effective Date:

Corporate Checking

Consumer Checking

Savings

__ __ / __ __ / __ __ __ __

If routing transit no. or bank account is new, please send a VOIDED check or deposit slip
Fax this completed form and attachments to:
USDA / Rural Development / RUS
DCFO / CMB
ATTN: Janice/Georgia
314 - 457-4370

OR

Mail this completed form with attachments to:
USDA/Rural Development/RUS
ATTN: Cash Management Branch
Mail Code: FC-363
P. O. Box 200011
St. Louis, MO 63120-0011

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection
of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0575-0184. The
time required to complete this information collection is estimated to average 30 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Privacy Act Statement
The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). The information requested on the form is required under
various provisions of title 15 U.S.C. 1601, 12 CFR 205 and 31 CFR 202, for the purpose of providing the authority to the Department of Treasury
to designate financial institutions to collect payments, by electronic means, from your account. The information will be used for identification with
the records of the government agency and the financial institution to direct your payments to the point you authorize.