Recipient Payment Information Form

OMB Approved No. 1505-0264

Expiration Date: 10/31/2020

Recipient Payment Information Form

April 17, 2020

To receive payment as soon as possible, recipients should submit completed payment materials not later than 11:59 p.m. EDT on April 17, 2020 to webpage address under construction. Payment forms received after April 17, 2020 may not be considered.

Payment Information form

Recipient Name
Recipient’s Taxpayer ID Number
Recipient’s DUNS Number
Recipient’s Address
Name of Authorized Representative for the Government Entity
Title of Authorized Representative for the Government Entity
Contact Person Name
Contact Person Title
Contact Person Phone
Contact Person E-mail

Recipient TYPE

Type of Recipient (choose one):

State/Territory

Local Government

Tribe

FINANCIAL INSTITUTION INFORMATION

Routing Transit Number (WIRE)
Routing Transit Number (ACH)
Recipient’s Account Number
Financial Institution Name
Financial Institution Address
Financial Institution Telephone Number

ADDITIONAL INFORMATION

Eligible local governments MUST also complete and submit the Certification form to receive direct payment from Treasury pursuant to sections 601(b)(2) and 601(e) of the Social Security Act, as added by section 5001 of the CARES Act.

PAPERWORK REDUCTION ACT NOTICE

The information collected will be used for the U.S. Government to process requests for support. The estimated burden associated with this collection of information is two hours per response. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Office of Privacy, Transparency and Records, Department of the Treasury, 1500 Pennsylvania Ave., N.W., Washington, D.C. 20220. DO NOT send the form to this address. 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 control number assigned by OMB.