RD-1951-65 Customer Initiated Payments Enrollment Form

Form Approved
OMB No. 0575-0184
Expires 00-00-0000

Form RD 1951-65
(04-11)
U.S. Department of Agriculture
Rural Development - St. Louis, Missouri
Customer Initiated Payments (CIP) Enrollment Form

Please process my request pertaining to the Customer Initiated Payments (CIP) program which uses the Automated Clearing House
(ACH) to pay my Rural Development loan. I understand that the CIP/ACH payments will only be made after my organization
schedules the payment on the CIP system.

Current Date: _____________________________

Effective Date of Action: _________________________

Action Requested:

Change

Add

Delete

BORROWER INFORMATION
Reference No. /
Primary Borrower ID:

____ ____ ____ ____ ____ ____ ____ ____ ____

Borrower Name:

___________________________________________________________________

Address:

___________________________________________________________________

City/State/Zip:

___________________________________________________________________

Contact Person/Title:

________________________________________________ (Please Print)

Signature of Contact:

______________________________________________ (Signature Only)

Telephone No.:

(_____)_______________________

Fax No.:

(_____)_______________________
BANKING INFORMATION
Old Banking Information

New Banking Information

Bank Routing Transit No.:

__ __ __ __ __ __ __ __ __

__ __ __ __ __ __ __ __ __

Bank Account No.:

__________________________

__________________________

Checking

Checking

Bank Acct Type:

Bank Account Nickname:

Savings

General
Ledger

__________________________

Savings

General
Ledger

__________________________

If adding or changing routing transit number or bank account, please send a VOIDED check or deposit slip.
Fax this completed form and attachments to:
USDA/Rural Development
Cash Management Branch
314-457-4370

or

Mail this completed form with attachments to:
USDA Rural Development
ATTN: Cash Management Branch
Bldg 104/FC-363
4300 Goodfellow Blvd.
St. Louis, MO 63120

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection
of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0575-0184. The
time required to complete this information collection is estimated to average 15 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
Privacy Act Statement
The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). The information requested on the form is required under
various provisions of title 15 U.S.C. 1601, 12 CFR 205 and 31 CFR 202, for the purpose of providing the authority to the Department of Treasury
to designate financial institutions to collect payments, by electronic means, from your account. The information will be used for identification with
the records of the government agency and the financial institution to direct your payments to the point you authorize.