ACH VENDOR/MISCELLANEOUS PAYMENT

ENROLLMENT FORM

This form is used for Automated Clearing House (ACH) payments with an
addendum record that contains payment-related information processed
through the Vendor Express Program. Recipients of these payments should
bring this information to the attention of their financial institution
when presenting this form for completion.

+-----------------+-----------------+-----------------+-----------------+
| 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 CFR |                 |                 |                 |
| 210. This       |                 |                 |                 |
| information     |                 |                 |                 |
| will be used by |                 |                 |                 |
| the Treasury    |                 |                 |                 |
| Department to   |                 |                 |                 |
| transmit        |                 |                 |                 |
| payment data,   |                 |                 |                 |
| by electronic   |                 |                 |                 |
| means to        |                 |                 |                 |
| vendor\'s       |                 |                 |                 |
| financial       |                 |                 |                 |
| institution.    |                 |                 |                 |
| Failure to      |                 |                 |                 |
| provide the     |                 |                 |                 |
| requested       |                 |                 |                 |
| information may |                 |                 |                 |
| delay or        |                 |                 |                 |
| prevent the     |                 |                 |                 |
| receipt of      |                 |                 |                 |
| payments        |                 |                 |                 |
| through the     |                 |                 |                 |
| Automated       |                 |                 |                 |
| Clearing House  |                 |                 |                 |
| Payment System. |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
|                 |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| AGENCY          |                 |                 |                 |
| INFORMATION     |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| FEDERAL PROGRAM |                 |                 |                 |
| AGENCY          |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| Battelle        |                 |                 |                 |
| Memorial        |                 |                 |                 |
| Institute --    |                 |                 |                 |
| Battelle        |                 |                 |                 |
| Pacific         |                 |                 |                 |
| Northwest       |                 |                 |                 |
| Division        |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| AGENCY          | AGENCY LOCATION | ACH FORMAT      |                 |
| IDENTIFIER      | CODE (ALC)      |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
|                 |                 |  CCD+  CTX   |                 |
|                 |                 | CTP             |                 |
+-----------------+-----------------+-----------------+-----------------+
| ADDRESS         |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| 902 Battelle    |                 |                 |                 |
| Blvd., MSIN     |                 |                 |                 |
| J1-04           |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| CITY            |                 | STATE           | ZIP CODE        |
+-----------------+-----------------+-----------------+-----------------+
| Richland        |                 | WA              | 99352           |
+-----------------+-----------------+-----------------+-----------------+
| CONTACT PERSON  |                 | CONTACT EMAIL   | CONTACT PHONE   |
| NAME            |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| Sue Williams    |                 | sue.w           | ( 509 ) 371     |
|                 |                 | illiams@pnl.gov | **-** 7560      |
+-----------------+-----------------+-----------------+-----------------+
| ADDITIONAL      |                 |                 |                 |
| INFORMATION     |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
|                 |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
|                 |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| PAYEE/COMPANY   |                 |                 |                 |
| INFORMATION     |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| NAME            |                 | SSN# or         |                 |
|                 |                 | TAXPAYER ID#    |                 |
+-----------------+-----------------+-----------------+-----------------+
|                 |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| ADDRESS         |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
|                 |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| CITY            |                 | STATE           | ZIP CODE        |
+-----------------+-----------------+-----------------+-----------------+
|                 |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| CONTACT PERSON  |                 | CONTACT EMAIL   | CONTACT PHONE   |
| NAME            |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
|                 |                 |                 | ( ) **-**       |
+-----------------+-----------------+-----------------+-----------------+
| NOTIFICATION    |                 | NOTIFICATION    |                 |
| EMAIL SAME AS   |                 | EMAIL (if       |                 |
| ABOVE?          |                 | different)      |                 |
+-----------------+-----------------+-----------------+-----------------+
|  YES or  NO   |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
|                 |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| FINANCIAL       |                 |                 |                 |
| INSTITUTION     |                 |                 |                 |
| INFORMATION     |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| NAME            |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
|                 |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| ADDRESS         |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
|                 |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| CITY            |                 | STATE           | ZIP CODE        |
+-----------------+-----------------+-----------------+-----------------+
|                 |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| ACH COORDINATOR |                 | COORDINATOR     | COORDINATOR     |
| NAME            |                 | EMAIL           | PHONE           |
+-----------------+-----------------+-----------------+-----------------+
|                 |                 |                 | ( ) **-**       |
+-----------------+-----------------+-----------------+-----------------+
| NINE-DIGIT      |                 |                 |                 |
| ROUTING TRANSIT |                 |                 |                 |
| NUMBER          |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
|                 | \[ \] \[ \] \[  |                 |                 |
|                 | \] \[ \] \[ \]  |                 |                 |
|                 | \[ \] \[ \] \[  |                 |                 |
|                 | \] \[ \]        |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| DEPOSITOR       |                 |                 |                 |
| ACCOUNT TITLE   |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
|                 |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| DEPOSITOR       |                 |                 | LOCKBOX NUMBER  |
| ACCOUNT NUMBER  |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
|                 |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
| TYPE OF ACCOUNT |                 |                 |                 |
+-----------------+-----------------+-----------------+-----------------+
|                 |  CHECKING      |  SAVINGS       |  LOCKBOX       |
+-----------------+-----------------+-----------------+-----------------+