Form SF-5510 Authorization Agreement for Preauthorized Payments

OMB No. 1510-0059

AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS

Expires (8/31/2007)

(AGENCY NAME)
Paperwork Reduction Act/Privacy Act Statement
The information requested on this form is required under 15 USC, Chapter 41, 12 CFR 205, and 31 CFR
202 and 206, for the purpose of authorizing the Department of the Treasury to designate financial
institutions to electronically collect payments from your account. This information will be used to match the
records of the government agency with those of the financial institution to direct your payments to the point
you authorize. No electronic collection from your account may be transacted unless a signed authorization
form is received. Furnishing this information is voluntary, however, failure to furnish this information may
delay or prevent the electronic collection of a payment through the Automated Clearing House. You are not
required to respond to a collection of information unless it displays a valid OMB control number. The valid
OMB control number for this collection of information is 1510-0059. We estimate that it will take
approximately 15 minutes to complete this form.

❑ START

CHECK ONE:

❑ CHANGE

❑ STOP

INDIVIDUAL/COMPANY INFORMATION
INDIVIDUAL/ORGANIZATION NAME: (PLEASE PRINT)
STREET ADDRESS:
CITY/STATE:

ZIP CODE:

TELEPHONE NUMBER:

AREA CODE:

YOUR AGENCY ACCOUNT IDENTIFICATION NUMBER:

TYPE OF PAYMENT:

I hereby authorize the initiation of a deduction from my account and the financial institution named below to debit such
account. I understand I will be notified if the debit amount needs to be adjusted, either to be increased or decreased. I
also understand that I have the right to stop automatic payment by notifying my financial institution in writing three days
prior to the time my account is charged.
SIGNATURE:

DATE:

FINANCIAL INSTITUTION INFORMATION
FINANCIAL INSTITUTION NAME:
STREET ADDRESS:
CITY/STATE:

ZIP CODE:

NINE - DIGIT ROUTING TRANSIT NUMBER:
ACCOUNT TITLE:
ACCOUNT NUMBER:
SIGNATURE AND TITLE OF REPRESENTATIVE:

STANDARD FORM 5510 (Rev. 2/2005)
Authorized for Local Reproduction
Previous Edition Not Usable

❑
❑
TELEPHONE NUMBER:

CHECKING
SAVINGS
AREA CODE:

DATE:

DEPARTMENT OF THE TREASURY
31 CFR 202 and 206: I TFM 6–8000