ACH Vendor/Miscellaneous Payment Enrollment Form

World Trade Center Health Program Enrollment, Appeals & Reimbursement

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0891 can be found here:

Documents and Forms

Document Name Document Type
Form 11 ACH Vendor/Miscellaneous Payment Enrollment Form Form and Instruction
11 ACH Vendor/Miscellaneous Payment Enrollment Form Attachment M SF 3881 ACH Vendor_Misc Payment Enrollment Form.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	ACH Vendor/Miscellaneous Payment Enrollment Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	11	ACH Vendor/Miscellaneous Payment Enrollment Form	Attachment M SF 3881 ACH Vendor_Misc Payment Enrollment Form.pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 200	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	200	200
Annual IC Time Burden (Hours)	50	50
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.