Form 10-002 Electronic Funds Transfer Waiver Request

DEPARTMENT OF HOMELAND SECURITY

U.S. Immigration and Customs Enforcement

ELECTRONIC FUNDS TRANSFER WAIVER REQUEST FORM

OMB No. 1653-XXXX

Expires XX-XX-XXXX

Federal regulations 31C.F.R. Part 208 and F.A.R. 32.11 give the Federal Government the authority to waive a vendor, sole proprietor, or individual from the Electronic Funds Transfer (EFT) requirements of the Debt Collection Improvement Act (DCIA) if they meet one or more of the seven conditions cited below. To request an EFT Waiver, please complete this form and submit it to the Director, Dallas Finance Center (DFC) or Director, Burlington Finance Center (BFC) by mail or facsimile for approval.

Vendor/Individual Name:
TIN (SSN, EIN, ITIN):
Address:
Point of Contact:
Phone No.:	( )	Facsimile No.:	( )
Email Address:
Business Type:	VENDOR- CORPORATION VENDOR- PARTNERSHIP VENDOR- SOLE PROPRIETOR INDIVIDUAL
Employee Status:	FEDERAL EMPLOYEE NON-FEDERAL EMPLOYEE

I request a waiver of the EFT payment requirement for the following reason(s):

INDIVIDUALS AND SOLE PROPRIETORS ONLY
	Condition 1 - It presents an unreasonable hardship due to physical or mental disability; geographic, language or literacy barrier; or financial impediment.
ALL VENDORS, SOLE PROPRIETORS AND INDIVIDUALS
	Condition 2 - The political, financial, or communications infrastructure in a foreign country (e.g., geographical territories outside of the United States and Puerto Rico) does not support payment by EFT.
	Condition 3 - Residence and duty station is designated as a disaster area. (This waiver is limited to payments made within 120 days after the disaster is declared.)
	Condition 4 - Payment by EFT is not possible or does not support the objectives of military operations, including contingency/emergency operations or civil emergencies.
	Condition 5 - Payment by EFT may pose a threat to national security, the life, or physical safety of an individual may be endangered, or a law enforcement action may be compromised.
	Condition 6 - The cost for making a payment by EFT exceeds the cost of making the payment by check and the recipient expects to receive a single, non-recurring payment within a one-year period.
	Condition 7 - Payment must be made by a method other than EFT where there is only one source or an agency’s need for goods and services is of such unusual and compelling urgency and the Federal Government would be seriously injured.

Payee/Requester ______________________ __________ Signature Date

For Office Use Only: Approved Denied Effective Date Signature of DFC/BFC Director Date

RETURN TO: OR:

Department of Homeland Security Department of Homeland Security

ICE-OCFO-OFM-DFC ICE-OCFO-OFM-BFC

Attention: Director, Dallas Finance Center (DFC) Attention: Director, Burlington Finance Center (BFC)

1460 Prudential Drive 166 Sycamore Street

Dallas, TX 75235 Williston, VT 05495

Facsimile: (214) 915-6262 Facsimile: (802) 288-1230

ICE Form 10-002 (XX/09)

Privacy Statement

Authority and Purpose:  The Debt Collection Improvement Act (31 U.S.C. § 3332), 31 C.F.R. Part 208, and Federal Acquisition Regulation Subpart 32.11 authorize the collection of this information to permit the processing of Electronic Funds Transfer (EFT) waiver requests for individuals and vendors.  Collection of your Social Security Number (SSN) is required by the U.S. Treasury Department in order to process federal payments to individuals and is authorized by 31 U.S.C. §§ 3325(d) and 7701, and Executive Order 9397.

Disclosure: Furnishing this information is voluntary; however, failure to provide it may result in the denial of the EFT waiver request.

Routine Uses: This information will be used by and disclosed to DHS personnel and contractors or other agents whose responsibilities include the processing of financial payments and EFT waivers. DHS may share this information with the U.S. Treasury Department or other agencies as needed to facilitate the issuance of federal payments. DHS may also share this information with the U.S. Justice Department and other Federal and State agencies for collection, enforcement, investigatory, or litigation purposes, or as otherwise authorized pursuant to its published Privacy Act system of records notice.

Public Reporting Burden.

The U.S. Immigration and Customs Enforcement is collecting this information as a part of its agency mission under the Department of Homeland Security. The estimated average time to review the instructions, search existing data sources, gather and maintain the data needed and completing and reviewing this collection of information is 30 minutes (.50 hours) per response. An agency may not conduct or sponsor, and a person is not required to respond to, an information collection unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the Department of Homeland Security, U.S. Immigration and Customs Enforcement, 500 12^th Street, S.W., Room 3138, Washington, D.C. 20536 (Do not mail your completed application to this address.)

ICE Form 10-002 (XX/09)