TDF 105.1 Authorization Agreement for Preauthorized Payments

OMB No. 1505-0245

The information requested on this form is required for the purpose of authorizing the Department of Treasury
Financial Research Fund to electronically collect semiannual assessment payments from your account.
Payments will be collected March 15 and September 15. An electronic billing notification detailing the amount of
the payment will be provided via E-mail approximately 14 days prior to collection. No electronic collection from
your account may be transacted unless a signed authorization form is received. We estimate that it will take
approximately 15 minutes to complete this form. Please submit completed form to
[email protected]; please include "FRF Assessments" in the subject line.

TDF 105.1 (rev. 07/2015)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The time required to complete this information collection is estimated to
average 15 minutes, including the time to review instructions, search existing data resources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Comments concerning the accuracy of
the time estimate and suggestions for reducing this burden should be directed to the Department of the Treasury, Departmental Offices, Financial Research Fund, 1500 Pennsylvania Ave., NW, Washington DC 20220.