Recipient Payment Information Form

OMB Approved No. 1505-0271

Expiration Date: November 30, 2021

Coronavirus State and Local Fiscal Recovery Funds

Recipient Payment Information Form

Eligible entities - States (defined to include the District of Columbia), U.S. Territories (defined to include, Puerto Rico, U.S. Virgin Islands, Guam, Northern Mariana Islands, and American Samoa), Tribes, Metropolitan cities, and Counties under the Coronavirus State and Local Fiscal Recovery Funds authorized by sections 602 and 603 of the Social Security Act as added by section 9901 of the American Rescue Plan Act of 2021, Pub. L. No. 117-2 (Mar. 11, 2021) may receive direct payment from Treasury by providing the following payment information.

‘Tribal Government’ means the recognized governing body of any Indian or Alaska Native tribe, band, nation, pueblo, village, community, component band, or component reservation, individually identified (including parenthetically) in the list published most recently

as of the date of enactment of this Act pursuant to section 104 of the Federally Recognized Indian Tribe List Act of 1994 (25 U.S.C. § 5131).

Nonentitlement units of local government will not receive a direct payment from Treasury. Treasury will make direct payments to States for distribution by the States to their respective nonentitlement units of local government.

PAYMENT INFORMATION

Recipient Name
Recipient’s Taxpayer ID Number
Recipient’s DUNS Number (Must correlate to the DUNS of the eligible entity, not a sub-entity.)
Recipient’s Address
Street
City
State
Postal Code
Name of Authorized Representative for the Government Entity*
Title of Authorized Representative for the Government Entity
Authorized Representative Email
* The Authorized Representative is the individual with legal authority to bind the payee or the Chief Executive Officer of the government entity. The Authorized Representative will receive an email to complete the certification signature process.
Contact Person Name
Contact Person Title
Contact Person Phone
Contact Person E-mail

RECIPIENT TYPE

Type of Recipient (choose one):

State/Territory/DC

Metropolitan City

Counties

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 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.