FS Form 00122 Request for Recurring Electronic Payments

Request for Recurring Electronic Payments

FS Form 000122
OMB No. 1530-XXXX

ATTENTION: Accounts Receivable Section (ARS)
(Name Change!Address Change if different from letter)
Account Type (Circle one):

Personal Checking Account
Personal Savings Account
Business Checking Account
Business Savings Account

Account Number (My Checking or Savings Account Number - from account type indicated
above)
Routing Number (If you are unsure of routing number, contact your financial institution for
information)
Financial Institution Name
Invoice #

Balance Due

Payment
Amount

Frequency of Payment
Monthly (Deducted by 15th of each month)

Phone Number(s) (Daytime Number Preferred)
E-Mail Address/Would you like a confirmation E-mail of this request?

Yes

No

I understand my first electronic payment will begin the month after this information is received
by the Bureau of the Fiscal Service, and my electronic payments will continue until my invoice(s)
is paid in full.

My Signature

Date

Comments:------------------------------------------------------------Note: All information must be complete in order to process your request for recurring electronic
payments.

Notice Under the Paperwork Reduction Act:
We estimate it will take you about 15 minutes to complete this form. However, you are not required to
provide information requested unless a valid OMB control number is displayed on the form. Any comments
or suggestions regarding this form should be sent to the Bureau of the Fiscal Service, Forms Management
Officer, Parkersburg, WV 26106-1328. DO NOT SEND completed form to the above address; send to
correct address shown in “Where to send” in the Instructions.