Form 10-002 Electronic Funds Transfer Waiver Request

OMB No. 1653-0043
Expires 11/30/2021

DEPARTMENT OF HOMELAND SECURITY

U.S. Immigration and Customs Enforcement
ELECTRONIC FUNDS TRANSFER WAIVER REQUEST FORM

Federal regulations 31 C.F.R. Part 208 and F.A.R. 32.11 give the Federal Government the authority to waive a vendor, sole proprietor, or
individual from the Electronic Funds Transfer (EFT) requirements of the Debt Collection Improvement Act (DCIA) if they meet one or more
of the seven conditions cited below. To request an EFT Waiver, please complete this form and submit it to Financial Service Center Dallas (FSC-D) by mail or facsimile for approval.

Vendor/Individual Name:
TIN (SSN, EIN, ITIN):
Bank Acct, Credit Card
or other Federal Acct No.
Address:
Point of Contact:
Phone No.:

Facsimile No.:

E-mail Address:
Business Type:

VENDOR-CORPORATION
INDIVIDUAL

Employee Status:

FEDERAL EMPLOYEE

VENDOR-PARTNERSHIP
NON-FEDERAL EMPLOYEE

VENDOR-SOLE PROPRIETOR
NON U.S. CITIZEN

I request a waiver of the EFT payment requirement for the following reason(s):
INDIVIDUALS AND SOLE PROPRIETORS ONLY
Condition 1 - It presents an unreasonable hardship due to physical or mental disability; geographic, language or
literacy barrier; or financial impediment.
ALL VENDORS, SOLE PROPRIETORS AND INDIVIDUALS
Condition 2 - The political, financial, or communications infrastructure in a foreign country (e.g., geographical
territories outside of the United States and Puerto Rico) does not support payment by EFT.
Condition 3 - Residence and duty station is designated as a disaster area. (This waiver is limited to payments
made within 120 days after the disaster is declared.)
Condition 4 - Payment by EFT is not possible or does not support the objectives of military operations, including
contingency/emergency operations or civil emergencies.
Condition 5 - Payment by EFT may pose a threat to national security, the life, or physical safety of an individual
may be endangered, or a law enforcement action may be compromised.
Condition 6 - The cost for making a payment by EFT exceeds the cost of making the payment by check and the
recipient expects to receive a single, non-recurring payment within a one-year period.
Condition 7 - Payment must be made by a method other than EFT where there is only one source or an
agency’s need for goods and services is of such unusual and compelling urgency and the Federal Government
would be seriously injured.
Payee/Requester
Signature (Sign in ink)

For Office Use Only:
Approved
Denied Effective Date
Date

Signature of Obligations Branch Manager Date
(Sign in ink)

RETURN TO:
Department of Homeland Security
ICE-OCFO-OFM-FSC-D
Attention: Deputy Division Chief Dallas Finance Center (DFC)
1605 LBJ Freeway, Suite 300
Farmers Branch, TX 75234
Email: [email protected]
ICE Form 10-002 (10/21)

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Privacy Notice
Authority: The Debt Collection Improvement Act (DCIA) (31 U.S.C. 3332), 31 CFR Part 208, and Federal Acquisition
Regulation Subpart 32.11 authorize the collection of this information to permit the processing of Electronic Funds Transfer
(EFT) waiver requests for individuals and vendors. Collection of your Social Security Number (SSN) is required by the U.
S. Treasury Department in order to process federal payments to individuals and is authorized by 31 U.S.C. 3325(d) and
7701, and Executive Order 9397.
Purpose: You are requesting an exemption and waiver from the EFT requirements of the DCIA.
Routine Uses: For United States Citizens, Lawful Permanent Residents, or individuals whose records are covered by the
Judicial Redress Act of 2015, 5 U.S.C. § 552a note, your information may be disclosed in accordance with the Privacy Act
of 1974, 5 U.S.C. § 552a(b), including pursuant to the routine uses published in the DHS/ALL-007 Accounts Payable
System of Records Notice (SORN), DHS/ALL-008 Accounts Receivable SORN, and DHS/ALL-019 Payroll, Personnel,
and Time and Attendance Records SORN, which can be viewed at www.dhs.gov/privacy.
For all others, as appropriate under United States law and U.S. Department of Homeland Security (DHS) policy, your
information and the information you provide may be shared internally within DHS and with personnel and contractors or
other agents who handle the processing of financial payments and EFT waivers. DHS may share this information with the
U.S. Treasury Department or other agencies as needed to facilitate the issuance of federal payments. DHS may also
share this information with the U.S. Justice Department and other Federal and State agencies for collection, enforcement,
investigatory, or litigation purposes, or as otherwise authorized.
Disclosure: Furnishing this information is voluntary; however, failure to provide it may result in the denial of the EFT
waiver request.

Public Reporting Burden
The U.S. Immigration and Customs Enforcement is collecting this information as a part of its agency mission under the
Department of Homeland Security. The estimated average time to review the instructions, search existing data sources,
gather and maintain the data needed, and complete and review this collection of information is 30 minutes (.50 hours) per
response. An agency may not conduct or sponsor, and a person is not required to respond to, an information collection
unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions, for reducing this burden to: U.S. Immigration and Customs
Enforcement, 1605 LBJ Freeway, Suite 300, Farmers Branch, TX 75234. OMB No. 1653-0043.

ICE Form 10-002 (10/21)

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