Local Assistance and Tribal Consistency Fund Recipient P

Local Assistance and Tribal Consistency Fund

1505-0276 LATCF Recipient Payment Information Form v3

Recipient Payment Information Form (for eligible revenue sharing counties)

OMB: 1505-0276

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OMB Approved No. 1505-0276

Expiration Date: MM/DD/YYYY

Local Assistance and Tribal Consistency Fund

Recipient Payment Information Form


PAYMENT INFORMATION


Recipient Name


Recipient’s Taxpayer ID Number


Recipient’s Unique Entity Identifier (UEI)


Recipient’s Address


Street


City


State


Postal Code



Name of Authorized Representative for the Recipient*


Title of Authorized Representative for the Recipient


Authorized Representative Email


* The Authorized Representative is the individual with legal authority to bind the Recipient or the Chief Executive Officer of the Recipient. The Authorized Representative will also complete certifications and assurances on behalf of the Recipient.


Contact Person Name


Contact Person Title


Contact Person Phone


Contact Person E-mail




RECIPIENT TYPE


Type of Recipient (choose one):


Eligible Revenue Sharing County (including the District of Columbia, the Commonwealth of Puerto Rico, Guam, and the United States Virgin Islands)


Eligible Tribal Government



FINANCIAL INSTITUTION INFORMATION


Routing Transit Number (WIRE) (Optional)


Routing Transit Number (ACH)


Recipient’s Account Number


Financial Institution Name


Financial Institution Address


Street


City


State


Postal Code


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 one hour 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.





File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorGary Grippo
File Modified0000-00-00
File Created2022-09-23

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