Recipient Payment Information Form

OMB Approved No. 1505-0264

Expiration Date:

U.S. Department of the Treasury
Coronavirus Relief Fund

Recipient Payment Information Form

July [?], 2021

Payment Information

Recipient’s Name
Recipient’s Taxpayer ID Number (EIN)
Recipient’s DUNS Number
Recipient’s Address
Street
City
State
Postal Code
The authorized representative is the individual with legal authority to bind the Recipient. The authorized representative will receive an email to complete the certification signature process.
Name of Authorized Representative for the Recipient
Title of Authorized Representative for the Recipient
Authorized Representative Email
The contact person will receive email updates if there are any questions regarding the information submitted as well as notification of payment scheduling. The contact person and the authorized representative can be the same person.
Contact Person Name
Contact Person Title
Contact Person Phone
Contact Person Email

Financial Institution Information

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

The authorized representative, by submitting this payment information and financial institution information, is, on behalf of the recipient named above (the “Recipient”), requesting a payment from the Department of the Treasury (“Treasury”) pursuant to section 601 of the Social Security Act (42 U.S.C. § 801) (the “Act”), as added by section 5001(a) of Division A of the CARES Act. This payment is subject to the restrictions on the use of funds provided in section 601(d) of the Act (42 U.S.C. § 601(d)) and guidance issued by Treasury, and the Recipient will be required to submit reports to Treasury with respect to the use of such funds.

I hereby certify that I am authorized by the Recipient to submit the information included in this form and that it is true and correct to the best of my knowledge. I further understand that a materially false, fictitious, fraudulent statement, or representation (or concealment or omission of a material fact) in this form may be the subject of criminal prosecution under the False Statements Accountability Act of 1996, as amended 18 U.S.C. § 1001, and also may subject me and the Recipient to civil penalties and administrative remedies for false claims or otherwise (including under to 31 U.S.C. §§ 3729 and 3730).

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Signature of Authorized Representative Authorized Representative Name: Authorized Representative Title: Date: 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 fifteen minutes 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.