Form NCUA 2005 NCUA 2005 Authorization Agreement for Electronic Funds Transfers P

National Credit Union Administration
AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER PAYMENTS
In accordance with the Debt Collection Improvement Act of 1996 (Public Law 104-134), the National Credit Union
Administration (NCUA) must make payments to credit unions by Electronic Funds Transfer (EFT).
PART I – MUST BE COMPLETED – Please print
NCUA CHARTER NUMBER (FCU) OR INSURANCE CERTIFICATE (FISCU)
CREDIT UNION NAME
ADDRESS
CITY

STATE

ZIP

EMPLOYER’S ID NO. [TAXPAYER ID NO].
CONTACT PERSON

PHONE NO.

EMAIL
FINANCIAL INSTITUTION NAME
9-DIGIT ROUTING & TRANSIT NO. (RTN)
ACCOUNT NO.
(Must be at least 4 digits, and only contain numbers, spaces, or dashes)
If using a Corporate credit union, please contact them to verify the correct RTN and account numbers for FedACH use.

PART II – OPTIONAL
As a convenience to credit unions, NCUA is now using a Treasury-developed program, Pay.Gov, to accept
electronic credit union payments to NCUA via direct debit on the invoice due date using the account info above.
If you do not elect Pay.Gov as a method of payment to NCUA, you must pay NCUA invoices by check.

Yes, please direct debit my credit union’s invoiced amounts through Pay.Gov.
PART III – MUST BE COMPLETED
I authorize NCUA to initiate electronic funds transfer payments to the credit union (and from the credit union if Pay.Gov
option was elected).
This authorization replaces all previous authorizations and remains in full force and effect unless NCUA receives a new
authorization, 60 days prior to the next established payment date .

NAME OF AUTHORIZED
REPRESENTATIVE

TITLE

SIGNED

DATE
PLEASE KEEP A COPY FOR YOUR RECORDS.

Please complete and return to:
By Fax to:
703-837-2400
By Email to:
[email protected]

National Credit Union Administration
OR
By Mail to:
National Credit Union Administration
Office of the Chief Financial Officer
1775 Duke Street
Alexandria, VA 22314-3428
OMB No. 3133-0135

PAPERWORK REDUCTION ACT STATEMENT: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.
The time required to complete this collection of information is estimated to average 15 minutes per response. This includes time for reviewing the instructions, gathering needed information, and completing and
reviewing the information. If you have comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, send comments to [email protected].
PRIVACY NOTICE: The personally identifiable information collected is used for following up with individuals regarding their interactions with federal and federally insured credit unions. NCUA securely maintains all personally
Identifiable information provided via emails and mail, and only shares it outside of NCUA if required by law or regulation. For additional information, please contact [email protected].
NCUA 2005