Form SF-5510 Authorization Agreement for Preauthorized Payment

AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS

OMB No.: 1510-0059
Expires: XX/XX/XX

(AGENCY NAME)
Paperwork Reduction Act/Privacy Act Statement
The information requested on this form is required under the Electronic Fund Transfer Act (15 USC § 1693 et seq.), 12 CFR 205
and 31CFR 206 and 210, for the purpose of authorizing the Department of Treasury to electronically collect payments from your
account. The information will be used to match the records of the government agency with those the financial institution to direct
your payments to the point you authorize. No preauthorized electronic fund transfer from your account may be transacted unless a
signed authorization form is received. Furnishing this information is voluntary; however, failure to furnish 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:

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

ZIP CODE:

AREA CODE:

TELEPHONE NUMBER:

YOUR AGENCY ACCOUNT IDENTIFICATION NUMBER:

TYPE OF PAYMENT:

I hereby authorize the initiation of the debit entries from my account listed below 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 to
be charged. I/We acknowledge that the origination of ACH transactions to my/our account must comply with U.S law. This authorization
is to remain in full force and effect until the agency listed above has received written notification from me in such time and in such
manner as to afford the agency listed above and the financial institution listed below a reasonable opportunity to act upon it.
For a business account, the signer of this form represents that he/she is authorized to approve debit entries to this account.
SIGNATURE: _________________________________________________________________

DATE: _________________________________

FINANCIAL INSTITUTION INFORMATION
FINACIAL INSTITUTION NAME:
STREET ADDRESS
CITY/STATE:

ZIP CODE:

NINE-DIGIT ROUTING TRANSIT NUMBER:

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ACCOUNT TITLE
ACCOUNT NUMBER

SIGNATURE AND TITLE OF REPRESENTATIVE

STANDARD FORM 5510 (Rev. 10/2010)
AUTHORIZED FOR LOCAL REPRODUCTION

CHECKING
SAVINGS
AREA CODE/TELEPHONE NUMBER

PREVIOUS EDITION NOT USABLE

DATE

DEPARTMENT OF THE TREASURY
12 CFR 205; 31 CFR 206 and 210; I TFM 6-8000