FS Form 2888 Application Form for U.S. Department of the Treasury Acc

APPLICATION FORM FOR U.S. DEPARTMENT OF THE TREASURY
ACCOUNTABLE OFFICIAL – ORGANIZATION STORED VALUE CARD (SVC)

OMB No. 1530-0020

DIRECTIONS: Submit completed form to Disbursing or Finance Office. Provide bank or credit union information if you are authorized to transfer funds from an
organizational bank or credit union account to your Accountable Official (AO) Treasury Stored Value Card (SVC) account at a Treasury SVC kiosk.
All form dates must be entered using the DDMMYYYY format.

ACCOUNTABLE ORGANIZATION BANK OR CREDIT UNION INFORMATION (Complete if applicable)
1. COMPANY/ORGANIZATION/MERCHANT ACCOUNT NAME (as it appears on your account)
3. CITY

4. STATE

5. ZIP CODE

8. ACCOUNT TYPE (X one)
☐ CHECKING
☐ SAVINGS

9. ABA ROUTING NUMBER (9-digits)

ACCOUNTABLE OFFICIAL PERSONAL INFORMATION
11. RATE, RANK, TITLE

12. FIRST NAME

13. MIDDLE INITIAL

2. DUTY STATION/SHIP

6. BANK OR CREDIT UNION NAME

7. EIN/TIN

10. ACCOUNT NUMBER

14. LAST NAME

15. MILITARY BRANCH (If applicable)

16. FULL SSN

18a. MILITARY DUTY/WORK ADDRESS (If military, include Division, Unit, etc.)

19a. RESIDENCE/PERMANENT ADDRESS (Must not be same as 18a)

b. CITY

b. CITY

c. STATE

20. WORK TELEPHONE NUMBER

d. ZIP CODE

e. COUNTRY

21. CELL PHONE NUMBER

17. DATE OF BIRTH

c. STATE

22. WORK E-MAIL ADDRESS

d. ZIP CODE

e. COUNTRY

23. PERSONAL E-MAIL ADDRESS

AUTHORIZATION TO MAKE TREASURY SVC TRANSFERS ELECTRONICALLY TO AND FROM BANK OR CREDIT UNION ACCOUNT

I authorize the U.S. Treasury’s Fiscal or Financial Agent to initiate debit and credit entries to the bank or credit union account at the financial institution specified
above in order to fulfill any requests I may make to transfer funds between the bank or credit union account and this Accountable Official - Organization Treasury
SVC account.
ACCOUNTABLE OFFICIAL LIABILITY: I acknowledge that I am the Accountable Official representing the organization for all funds placed on this card and may
be held pecuniarily liable for the loss or misuse of such funds. I may be relieved of such liability only under the procedures detailed in DoD FMR Volume 5, Ch 1.
EXPIRED, LOST, STOLEN, OR DAMAGED CARD: When the Accountable Official – Organization Treasury SVC card expires, any value remaining may be
forwarded to the bank or credit union account specified above. If the account has been closed or if any value remaining on the card cannot be forwarded to the
account for any other reason, I understand that the funds may be transferred to an account in the U.S. Treasury in accordance with 31 U.S.C. 1322 or elsewhere
in accordance with applicable law. The organization listed in Items 1 and 7 retains the right to claim such finds. If my Accountable Official – Organization Treasury
SVC is lost, stolen or damaged, I may be charged a fee for a replacement card. ADDITIONAL TERMS AND CONDITIONS: By using the Accountable Official –
Organization Treasury SVC, I agree to accept the terms and conditions for use of the Accountable Official Treasury SVC established by the issuer of the card.
This form may be imaged and kept on file electronically by the U.S. Department of the Treasury and/or its Financial or Fiscal Agent, and an electronic image shall
be considered the legal equivalent of the original. I represent and warrant that the organization listed in Items 1 and 7 has authorized me to obtain this
Accountable Official – Organization Treasury SVC, to link it to the bank or credit union account listed above, and to hold, collect, and disburse funds that are in the
account and on this Accountable Official – Organization Treasury SVC. I agree to return the Accountable Official – Organization Treasury SVC when I no longer
hold the position as accountable officer for the funds and/or Accountable Officer – Organization SVC account.

PRIVACY ACT STATEMENT
AUTHORITY: Executive Order 9397, 31 CFR 210, and 31 U.S.C. 7701. PRINCIPAL PURPOSES: To enroll individuals acting in the capacity of Accountable

Officials in the Treasury SVC program; to obtain authorization to initiate debit and credit entries to bank and credit union accounts; and to facilitate collection of
any delinquent amounts. ROUTINE USES: The information on this form may be disclosed as generally permitted under 5 U.S.C. Section 552a(b) of the Privacy
Act of 1974, as amended. It may be disclosed outside of the U.S. Department of the Treasury, Fiscal and Financial Agents involved in providing SVC services,
and their contractors or to the Department of Defense (DoD) for the purpose of administering the Treasury SVC programs. In addition, other Federal, State, or
local government agencies that have identified a need to know may obtain this information for the purpose(s) identified by the Bureau of the Fiscal Service (Fiscal
Service) Routine Uses as published in the Federal Register. Aggregate data about transactions captured both on and off the installation or ship, whether through
the card’s electronic purse or magnetic strip, may be used to generate summary level reports. DISCLOSURE: Disclosure is voluntary; however, failure to furnish
requested information may prevent you from participating in the Treasury SVC programs. Your SSN and the organization’s EIN/TIN is being requested to verify
your and its identity and to facilitate the collection of any amounts that may become due to the government as a result of your use of the Treasury SVC. If you do
not provide your SSN and the organization’s EIN/TIN, we cannot process your application for a SVC.

24. POSITION TO WHICH APPOINTED

25. SIGNATURE

26. DATE SIGNED

FOR OFFICE USE ONLY
27. SIGNATURE OF ISSUER:

28. PRINTED NAME

29. CARD NUMBER (Last 7 digits)

30. DATE ISSUED

BURDEN ESTIMATE STATEMENT

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 10 minutes, including the time to review instructions, search existing
data sources, gather and maintain the data needed, and complete and review the collection of information. Comments concerning the accuracy of the time
estimate and suggestions for reducing this burden should be directed to the U.S. Department of the Treasury, Bureau of the Fiscal Service, 401 14th Street SW,
Washington DC 20227.

FS FORM 2888 (08-21)

DEPARTMENT OF THE TREASURY
BUREAU OF THE FISCAL SERVICE