Form 190-F-05-001 Fellowship Stipend Payment Enrollment Form

United States
ENVIRONMENTAL PROTECTION AGENCY
Washington, DC 20460

OMB Control No. 2030-0020
Approval expires MM/DD/YYYY
For internal use only

FELLOWSHIP STIPEND PAYMENT
ENROLLMENT FORM
This collection of information is approved by OMB under the Paperwork Reduction Act, 44 U.S.C. 3501 et seq. (OMB Control No. 2030-0020). Responses to this collection of information
are required to obtain an assistance agreement (40 CFR Part 30, 40 CFR Part 31, and 40 CFR Part 33 for awards made prior to December 26, 2014, and 2 CFR 200, 2 CFR 1500, and 40 CFR
Part 33 for awards made after December 26, 2014). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently
valid OMB control number. The public reporting and recordkeeping burden for this collection of information is estimated to be 0.5 hours per response. Send comments on the Agency’s need
for this information, the accuracy of the provided burden estimates and any suggested methods for minimizing respondent burden to the Regulatory Support Division Director, U.S.
Environmental Protection Agency (2821T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed
form to this address.

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
Treasury Department to transmit payment data, by electronic means to vendor's financial institution. Failure to provide the
requested information may delay or prevent the receipt of payments through the Automated Clearing House Payment
System.

EPA INFORMATION
FEDERAL PROGRAM AGENCY

U.S. ENVIRONMENTAL PROTECTION AGENCY
AGENCY IDENTIFIER:

AGENCY LOCATION CODE (ALC):

RTPFC

68128933

ADDRESS:

4930 PAGE RD (Mail Code AA216-01)

DURHAM, NC 27703
CONTRACT PERSON NAME:

Research Triangle Park Finance Center

EMAIL: [email protected]

TELEPHONE NUMBER

(919) 541-1550

ADDITIONAL INFORMATION

FELLOW’S INFORMATION
NAME

SOCIAL SECURITY NUMBER

ASSISTANCE ID/FELLOWSHIP NUMBER
ADDRESS
CONTACT PERSON EMAIL ADDRESS:

TELEPHONE NUMBER:

(

)

FELLOW’S BANK INFORMATION (STIPEND WILL BE SENT TO YOUR BANK BY EFT)
BANK NAME:
BANK ADDRESS:

NINE-DIGIT ROUTING TRANSIT NUMBER:
NAME ON ACCOUNT:
ACCOUNT NUMBER:
TYPE OF ACCOUNT:
CHECKING
FELLOW’S AUTHORIZING SIGNATURE:

SAVINGS
TELEPHONE NUMBER:

(
EPA 190-F-05-001

)

NOTE: The intention of this form is to establish Direct Deposit for Stipends payable to Fellowship recipients. This is not a
mandatory requirement but highly recommended. If you don’t have a bank account - DO NOT FILL OUT THIS FORM,
instead your Stipend will be forwarded by check via mail.
Instructions for the Fellowship Stipend Payment Enrollment Form:
Under FELLOW’S INFORMATION:
- Enter your name
- Enter your Social Security Number
- Enter your Assistance ID/Fellowship Number (it usually starts with U, FP or MA, located on the top center of your
Fellowship Agreement)
- Enter your mailing address
- Enter your email address
- Enter your telephone number
Under FELLOW’S BANK INFORMATION:
- Enter your banking institutions name
- Enter your banking institutions complete address (local bank address only)
- Enter your nine-digit routing number (see illustration)
- Enter the name the account is under (your name or parents, etc.)
- Enter your bank account number (see illustration)
- Enter what type of account (Checking or Savings)
- Enter signature and telephone number

Routing Number

Acct Number

(Do not use the numbers from a deposit slip)

EPA 190-F-05-001

Do not use