FOR ECHO PAYMENTS ONLY

  -----------------------------------------------------------------------
  **PAYMENT INFORMATION FORM - ACH PAYMENT SYSTEM**

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ECHO Control Number (ECN) (For initial ECHO setup agency will assign ECN
Number)

Initial Setup ![](media/image1.wmf){width="0.2125in" height="0.2125in"}
Info Change ![](media/image1.wmf){width="0.2125in" height="0.2125in"}
Grantee Information Change
![](media/image1.wmf){width="0.3145833333333333in"
height="0.3145833333333333in"}

> Information from this form is required under the provision of 31
> U.S.C. 3322 and 31 CFR 210. Treasury uses this to transmit payment
> data by electronic means to a company\'s or a grantee\'s financial
> institution. Failure to provide the requested information may delay or
> prevent the receipt of payments through the Treasury ACH Payment
> System.

Note: See back for instructions on completing this form.

+-------------------------------+-----------------+--------------------+
| **GRANTEE/COMPANY             |                 |                    |
| INFORMATION**                 |                 |                    |
+===============================+=================+====================+
| **NAME:**                     |                 |                    |
+-------------------------------+-----------------+--------------------+
| **ADDRESS:**                  |                 |                    |
+-------------------------------+-----------------+--------------------+
|                               |                 | **TIN:**           |
+-------------------------------+-----------------+--------------------+
| **CITY/STATE/ZIP:**           |                 | **TELEPHONE        |
|                               |                 | NUMBER:**          |
|                               |                 |                    |
|                               |                 | **( )**            |
+-------------------------------+-----------------+--------------------+
| **CONTACT PERSON NAME:**      |                 |                    |
+-------------------------------+-----------------+--------------------+
| **SIGNATURE OF AUTHORIZED     |                 | **FAX NUMBER:**    |
| OFFICIAL IN FTA**             |                 |                    |
|                               |                 | **( )**            |
+-------------------------------+-----------------+--------------------+
|                               | **DATE: / /**   |                    |
+-------------------------------+-----------------+--------------------+

+--------------------------------------+------+---+----------------------+
| **AGENCY INFORMATION**               |      |   |                      |
+======================================+======+===+======================+
| **NAME:** *Federal Transit           |      |   |                      |
| Administration*                      |      |   |                      |
+--------------------------------------+------+---+----------------------+
| **ADDRESS:** *400 7th Street SW,     |      |   |                      |
| Room 9422, TBP-50, Washington, D.C.  |      |   |                      |
| 20590*                               |      |   |                      |
+--------------------------------------+------+---+----------------------+
| **CONTACT PERSON NAME:** *Edith      |      | * |                      |
| McLamore-Shelton*                    |      | ( |                      |
|                                      |      | 2 |                      |
|                                      |      | 0 |                      |
|                                      |      | 2 |                      |
|                                      |      | ) |                      |
|                                      |      | 3 |                      |
|                                      |      | 6 |                      |
|                                      |      | 6 |                      |
|                                      |      | - |                      |
|                                      |      | 9 |                      |
|                                      |      | 7 |                      |
|                                      |      | 4 |                      |
|                                      |      | 8 |                      |
|                                      |      | * |                      |
+--------------------------------------+------+---+----------------------+
| **FINANCIAL INSTITUTION              |      |   |                      |
| INFORMATION**                        |      |   |                      |
|                                      |      |   |                      |
| **(Note: Have Your Bank Complete     |      |   |                      |
| This Section)**                      |      |   |                      |
+--------------------------------------+------+---+----------------------+
| **NAME:**                            |      |   |                      |
+--------------------------------------+------+---+----------------------+
| **ADDRESS:**                         |      |   |                      |
+--------------------------------------+------+---+----------------------+
| **CITY/STATE/ZIP:**                  |      |   |                      |
+--------------------------------------+------+---+----------------------+
| **CONTACT PERSON NAME:**             |      |   | **TELEPHONE          |
|                                      |      |   | NUMBER:**            |
|                                      |      |   |                      |
|                                      |      |   | **( )**              |
+--------------------------------------+------+---+----------------------+
|                                      |      |   |                      |
+--------------------------------------+------+---+----------------------+
| **NINE DIGIT ROUTING TRANSIT         |      |   |                      |
| NUMBER:**                            |      |   |                      |
+--------------------------------------+------+---+----------------------+
| **DEPOSITOR ACCOUNT TITLE:**         |      |   |                      |
+--------------------------------------+------+---+----------------------+
| **DEPOSITORS ACCOUNT NUMBER:**       |      |   |                      |
+--------------------------------------+------+---+----------------------+
| **TYPE OF ACCOUNT: CHECKING SAVING** |      |   |                      |
+--------------------------------------+------+---+----------------------+
| **SIGNATURE AND TITLE OF             | *    |   | **FAX NUMBER:**      |
| REPRESENTATIVE:**                    | *DAT |   |                      |
|                                      | E:** |   | **( )**              |
|                                      |      |   |                      |
|                                      | **/  |   |                      |
|                                      | /**  |   |                      |
+--------------------------------------+------+---+----------------------+
|                                      |      |   |                      |
+--------------------------------------+------+---+----------------------+

Revised 02/2000

**INSTRUCTIONS FOR COMPLETING**

**"PAYMENT INFORMATION FORM"**

1.  Fill in your ECHO Control Number (ECN) if applicable. If this is an
    Initial ECHO Setup, agency will assign ECHO Control Number.

2.  Check appropriate box(es)

    -   Initial setup

    -   Change in bank information

    -   Change in grantee information

3.  Fill out information in the appropriate section(s) listed below:

    -   **Grantee/Company Information Section** -Print or type the name
        of the grantee/company that will receive ECHO/ACH payments. Also
        include the contact person\'s name, address, telephone and fax
        numbers.

    -   **TIN**: Please be sure to include the Tax Identification Number
        (TIN). Failure to do so or an incorrect TIN may delay or prevent
        the receipt of payments through the Treasurer's ACH payment
        system.

    -   **Financial Institution Information Section** -Have your bank
        fill out this section. They should print or type the name and
        address They should print or type the name and address of the
        financial institution who will receive the ECHO/ACH payment.
        Also included are the ACH coordinator\'s name, telephone number,
        nine-digit routing transit number (ABA#), depositor (grantee)
        account title, depositor (grantee) account number, and type of
        account (type can ONLY be designated checking or saving),
        signature and title of bank representative, date and fax number.

4.  Mail the completed form to the FTA Regional contact for ECHO. For
    Region 10:

> Elizabeth Sier
>
> ECHO Liaison
>
> Federal Transit Administration
>
> 915 2ndAvenue, Room 3142
>
> Seattle, Washington 98174
>
> Phone: 206-220-7956
>
> FAX: 206-220-7959