Form SF-5510 AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS

AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS OMB No.: 1510-0059

Expires: 11/30/2010

(AGENCY NAME)

Paperwork Reduction Act/Privacy Act Statement

The information requested on this form is required under the Electronic Fund Transfer Act (15 USC § 1693 et seq.), 12 CFR 205 and 31CFR 206 and 210, for the purpose of authorizing the Department of Treasury to electronically collect payments from your account. The information will be used to match the records of the government agency with those the financial institution to direct your payments to the point you authorize. No preauthorized electronic fund transfer from your account may be transacted unless a signed authorization form is received. Furnishing this information is voluntary; however, failure to furnish 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.

CHECK ONE: START CHANGE STOP

INDIVIDUAL/ COMPANY INFORMATION

INDIVIDUAL/ORGANIZATION NAME (PLEASE PRINT)
STREET ADDRESS
CITY/STATE:		ZIP CODE:
AREA CODE:	TELEPHONE NUMBER:
YOUR AGENCY ACCOUNT IDENTIFICATION NUMBER:		TYPE OF PAYMENT:

I hereby authorize the initiation of the debit entries from my account listed below 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 to be charged. I/We acknowledge that the origination of ACH transactions to my/our account must comply with U.S law. This authorization is to remain in full force and effect until the agency listed above has received written notification from me in such time and in such manner as to afford the agency listed above and the financial institution listed below a reasonable opportunity to act upon it.

For a business account, the signer of this form represents that he/she is authorized to approve debit entries to this account.

SIGNATURE: _________________________________________________________________ DATE: _________________________________

FINANCIAL INSTITUTION INFORMATION

FINACIAL INSTITUTION NAME:

STREET ADDRESS

CITY/STATE:

ZIP CODE:

NINE-DIGIT ROUTING TRANSIT NUMBER: ►

ACCOUNT TITLE

ACCOUNT NUMBER CHECKING SAVINGS

SIGNATURE AND TITLE OF REPRESENTATIVE

AREA CODE/TELEPHONE NUMBER

DATE

STANDARD FORM 5510 (Rev. 10/2010) PREVIOUS EDITION NOT USABLE DEPARTMENT OF THE TREASURY

AUTHORIZED FOR LOCAL REPRODUCTION 12 CFR 205; 31 CFR 206 and 210; I TFM 6-8000