Single Family Premium Collection Subsystem-Upfront

ACH Program Application
Title I Insurance Charge
Payments System

U.S. Department of Housing
and Urban Development
Office of Housing
Federal Housing Commissioner

OMB Approval No. 2502-0512 (Exp. 2/28/2011)

Public reporting burden for this collection of information is estimated to average 15 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. HUD may not collect
this information, and you are not required to complete this form, unless it displays a currently valid OMB control number.
Section 201.31 of the Title I Regulations, relating to payments of insurance charges, has been amended. The regulations permit the Secretary of HUD to
require Title I lenders to pay insurance charges through the Automated Clearing House (ACH) Program. This collection is necessary for obtaining needed
data from Title I lenders for use of the ACH program.

Complete a separate form for each contract number. This form may be photocopied.
Please print or type all information.
U.S. Department of Housing and Urban Development
Mail the
Albany Financial Operations
completed
Method of Transmission (check one)
Premium Branch
form to:
52 Corporate Circle
Terminal Input
CPU to CPU *
Albany, NY 12203
Name & Address of Lending Institution

Lender Contract Number (6-digit number)

Name & Address of Bank

Bank Account Number

Type of Account (Please check)

Savings account

Checking account

Bank's ABA Number (Transit Routing (TR) 9-digit number)

Name of Primary Contact Person

Telephone Number (Include Area Code)

Name of Alternate Contact Person

Telephone Number (Include Area Code)

Signature of Authorizing Official

Title

Date

* For CPU to CPU clients only: Please complete the following:
1. Name of Technical Contact Person

Telephone Number (Include Area Code)

2. Computer Type

3. FAX Number for receiving transmission confirmation

4. Communication Device

Instructions for CPU Clients
1. Provide the name and telephone number of the client's technical contact, i.e., the person responsible for telecommunications hardware
or software who will be directly involved in the communications testing.
2. Indicate the type of computer hardware being used, e.g., IBM (or compatible), UNISYS, DEC.
3. Provide the FAX number for receiving the transmission confirmation report.
4. Provide a brief description of the dial-up modem being used and its functional characteristics, e.g., Baud line speed, Dataphone brand/
model, Protocol.
form HUD-56150 (6/95)