SF 5510 Authorization Agreement for Preauthorized Payments

AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS

OMB No.: 1510-0059
Expires: 01/31/2014

(AGENCY NAME)
Paperwork Reduction Act/Privacy Act Statement
The information requested on this form is required under various provisions of title 15 USC Chapter 41, 12 CFR 205, and 31
CFR 202 and 206, for the purpose of authorizing the Department of Treasury to designate financial institutions to electronically
collect payments from your account. The 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.

CHECK ONE:

START

CHANGE

STOP

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

ZIP CODE:

AREA CODE:

TELEPHONE NUMBER:
TYPE OF PAYMENT:

YOUR AGENCY ACCOUNT IDENTIFICATION NUMBER:

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

CHECKING
SAVINGS

SIGNATURE AND TITLE OF REPRESENTATIVE

STANDARD FORM 5510 (Rev. 2/2005)
AUTHORIZED FOR LOCAL REPRODUCTION

AREA CODE/TELEPHONE NUMBER

PREVIOUS EDITION NOT USABLE

DATE

DEPARTMENT OF THE TREASURY
31 CFR 202 and 206; I TFM 6-8000