OMB #1123-0013 USVSST Direct Deposit Form

U.S. Victims of State Sponsored Terrorism Fund Direct Deposit – ACH Payment Form OMB No. 1123‑0013 Expires [DATE]

PAYEE INFORMATION

Payee Name

FINANCIAL INSTITUTION INFORMATION

Bank Name

Bank City, State

Bank Routing Number (9 Digits)

____ ____ ____ ____ ____ ____ ____ ____ ____

Account Number

PRIVACY ACT STATEMENT

The following information is provided to comply with the Privacy Act of 1974 (P.L. 93‑579). All information collected on this form is required under the provisions of 31 U.S.C.§ 3322 and 31 C.F.R.§ 210. This information will be used by the United States Department of Justice to transmit payment data, by electronic means to payee’s financial institution. Failure to provide the requested information may delay or prevent the receipt of payments through the Automated Clearing House System.