Form 10-002 Electronic Funds Transfer Waiver Request

DEPARTMENT OF HOMELAND SECURITY
U.S. Immigration and Customs Enforcement

ELECTRONIC FUNDS TRANSFER WAIVER REQUEST FORM
OMB No. 1653-0043
Expires 3/31/2015
Federal regulations 31 C.F.R. Part 208 and F.A.R. 32.11 give the Federal Government the authority to waive a vendor, sole proprietor,
or individual from the Electronic Funds Transfer (EFT) requirements of the Debt Collection Improvement Act (DCIA) if they meet one or
more of the seven conditions cited below. To request an EFT Waiver, please complete this form and submit it to the Director, Dallas
Finance Center (DFC) or Director, Burlington Finance Center (BFC) by mail or facsimile for approval.

Vendor/Individual
Name:
TIN (SSN, EIN, ITIN):
Address:
Point of Contact:
Phone No.:
E-mail Address:

Facsimile No.:

Business Type:

VENDOR- CORPORATION
INDIVIDUAL

VENDOR- PARTNERSHIP

Employee Status:

FEDERAL EMPLOYEE

NON-FEDERAL EMPLOYEE

VENDOR- SOLE PROPRIETOR

I request a waiver of the EFT payment requirement for the following reason(s):
INDIVIDUALS AND SOLE PROPRIETORS ONLY
Condition 1 - It presents an unreasonable hardship due to physical or mental disability; geographic,
language or literacy barrier; or financial impediment.
ALL VENDORS, SOLE PROPRIETORS AND INDIVIDUALS
Condition 2 - The political, financial, or communications infrastructure in a foreign country (e.g.,
geographical territories outside of the United States and Puerto Rico) does not support payment by EFT.
Condition 3 - Residence and duty station is designated as a disaster area. (This waiver is limited to
payments made within 120 days after the disaster is declared.)
Condition 4 - Payment by EFT is not possible or does not support the objectives of military operations,
including contingency/emergency operations or civil emergencies.
Condition 5 - Payment by EFT may pose a threat to national security, the life, or physical safety of an
individual may be endangered, or a law enforcement action may be compromised.
Condition 6 - The cost for making a payment by EFT exceeds the cost of making the payment by check
and the recipient expects to receive a single, non-recurring payment within a one-year period.
Condition 7 - Payment must be made by a method other than EFT where there is only one source or an
agency’s need for goods and services is of such unusual and compelling urgency and the Federal
Government would be seriously injured.
For Office Use Only:
Approved
Denied

Payee/Requester

Signature

Date

RETURN TO:
Department of Homeland Security
ICE-OCFO-OFM-DFC
Attention: Director, Dallas Finance Center (DFC)
1460 Prudential Drive
Dallas, TX 75235
Facsimile: (214) 915-6262
ICE Form 10-002 (07/11)

Effective Date

Signature of DFC/BFC Director

Date

OR:
Department of Homeland Security
ICE-OCFO-OFM-BFC
Attention: Director, Burlington Finance Center (BFC)
166 Sycamore Street
Williston, VT 05495
Facsimile: (802) 288-1230
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Privacy Statement
Authority and Purpose: The Debt Collection Improvement Act (31 U.S.C. § 3332), 31 C.F.R. Part 208, and
Federal Acquisition Regulation Subpart 32.11 authorize the collection of this information to permit the
processing of Electronic Funds Transfer (EFT) waiver requests for individuals and vendors. Collection of your
Taxpayer Identification Number (TIN) or Social Security Number (SSN) is required by the U.S. Treasury
Department in order to process federal payments to individuals and is authorized by 31 U.S.C. §§ 3325(d) and
7701, and Executive Order 9397.
Disclosure: Furnishing this information is voluntary; however, failure to provide it may result in the denial of
the EFT waiver request.
Routine Uses: This information will be used by and disclosed to DHS personnel and contractors or other
agents whose responsibilities include the processing of financial payments and EFT waivers. DHS may share
this information with the U.S. Treasury Department or other agencies as needed to facilitate the issuance of
federal payments. DHS may also share this information with the U.S. Justice Department and other Federal
and State agencies for collection, enforcement, investigatory, or litigation purposes, or as otherwise authorized
pursuant to its published Privacy Act system of records notice.
Public Reporting Burden.
The U.S. Immigration and Customs Enforcement is collecting this information as a part of its agency mission
under the Department of Homeland Security. The estimated average time to review the instructions, search
existing data sources, gather and maintain the data needed, and complete and review this collection of
information is 30 minutes (.50 hours) per response. An agency may not conduct or sponsor, and a person is
not required to respond to, an information collection unless it displays a currently valid OMB Control Number.
Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions, for reducing this burden to: PRA Officer / Forms Management / Office of the Chief Information
Office / U.S. Immigration and Customs Enforcement, 801 I Street NW Stop-5800, Washington DC 20536-5800
(Do not mail your completed application to this address)

ICE Form 10-002 (07/11)

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