Recipient Payment Information Form

OMB Approved No.

Expiration Date:

RECIPIENT PAYMENT INFORMATION FORM

Eligible entities— States (defined as a state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, American Samoa, the United States Virgin Islands, the Commonwealth of the Northern Mariana Islands), the Department of Hawaiian Home Lands, and certain Indian Tribes or Tribally designated housing entities eligible for payment under section 3206(f) of the American Rescue Plan Act of 2021, —must provide the following payment information.

RECIPIENT INFORMATION

Recipient Name

Recipient’s Taxpayer ID Number

Recipient's DUNS Number

Recipient’s Address

Street

City

State

Postal Code

Authorized Representative Name

Authorized Representative Title

Authorized Representative Email

Contact Person Name

Contact Person Title

Contact Person Phone

Contact Person E-mail

RECIPIENT TYPE

Type of recipient (choose one):

• State/DC

• Territorial Government

• Indian Tribe or Tribally Designated Housing Entity

• Department of Hawaiian Homelands

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

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 15 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.

PRIVACY ACT STATEMENT

AUTHORITY:  Solicitation of this information is authorized by the American Rescue Plan Act of 2021, Title III, Pub. L. 117-2.

PURPOSE:  Treasury is required by the American Rescue Plan Act of 2021 to identify eligible entities to provide homeowners assistance to individuals who qualify for relief under the Act.  Eligible entities are state, territorial, and tribal governments, which will identify homeowners eligible for relief based on requirements under the Act.  Treasury maintains contact information for authorized representatives and contact persons for the purpose of communicating with eligible entities regarding issues related to implementation of the Act.

ROUTINE USES: The information you furnish may be shared in accordance with the routine uses outlined in the Treasury’s system of records notice, Treasury .017 - Correspondence and Contact Information, which can be found at 81 FR 78266 (Nov. 7, 2016).

DISCLOSURE: Disclosure of this information to Treasury is required in order to comply with the requirements the American Rescue Plan Act of 2021.  Disclosure of this information is voluntary, however, grantees/recipients that do not disclose contact information will be unable to communicate with Treasury on issues related to their obligations under the Act and this may affect the status of their grant.