Information Collection

ACH Vendor/Miscellaneous Payment Enrollment Form

IC 200509 under ICR 201406-0920-001 · OMB 0920-0891.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.