Direct Deposit Payment Form

U.S. VICTIMS OF STATE
SPONSORED TERRORISM FUND
Direct Deposit - ACH Payment Form
OMB No. 1123-0013
PAYEE INFORMATION
NAME

SS #

ADDRESS
TELEPHONE NUMBER

(

)

FINANCIAL INSTITUTION INFORMATION
BANK NAME
BANK CITY, STATE
BANK ROUTING NUMBER (9 DIGITS)

___ ___ ___ ___ ___ ___ ___ ___ ___
CHECKING
SAVINGS

ACCOUNT NUMBER

Pat Smith
123 Main Street
City, State 54321

If you have questions
about your Bank
Routing Number or
Account Number,
please request
assistance from your
Financial Institution.

SIGNATURE

DATE

PRIVACY ACT STATEMENT
The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). All information
collected on this form is required under the provisions of 31 U.S.C. 3322 and 31 CFR 210. This information
will be used by the Justice Department to transmit payment data, by electronic means to payee’s financial
institution. Failure to provide the requested information may delay or prevent the receipt of payments
through the Automated Clearing House System.