**TENNESSEE VALLEY AUTHORITY (TVA)**

**ELECTRONIC VENDOR PAYMENT FORM**

**[Please TAB to gray areas]{.mark}**

<table>
<colgroup>
<col style="width: 4%" />
<col style="width: 6%" />
<col style="width: 1%" />
<col style="width: 21%" />
<col style="width: 0%" />
<col style="width: 12%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 8%" />
<col style="width: 36%" />
<col style="width: 3%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="11"><strong>COMPANY/SUPPLIER INFORMATION</strong></td>
</tr>
<tr class="even">
<td colspan="2"><blockquote>
<p>Name:</p>
</blockquote></td>
<td colspan="8">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="4"><blockquote>
<p>Taxpayer Identification Number</p>
</blockquote></td>
<td colspan="6">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="5"><blockquote>
<p>Accts. Receivable Contact Name:</p>
</blockquote></td>
<td colspan="5">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="3"><blockquote>
<p>Phone #:</p>
</blockquote></td>
<td colspan="3">(     )      </td>
<td colspan="3">Fax #:</td>
<td>(     )      </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="11"><blockquote>
<p><strong>Select one of the options below to receive your remittance
information:</strong></p>
</blockquote></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="6">Send remittance information to fax machine #</td>
<td colspan="3">(     )      </td>
<td>.</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="7">Send remittance information to e-mail address</td>
<td colspan="2">     </td>
<td></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="10">Send remittance information to bank with payment</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="10">Send remittance information to EDI mailbox. If this
selection is made, provide the following:</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="10">Sender/receiver ID; Qualifier ID; VAN; and brand of EDI
software.</td>
</tr>
<tr class="even">
<td></td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="9">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"></td>
</tr>
</tbody>
</table>

<table>
<colgroup>
<col style="width: 16%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 6%" />
<col style="width: 9%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 3%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="29"><strong>FINANCIAL INSTITUTION INFORMATION</strong></td>
</tr>
<tr class="even">
<td><blockquote>
<p>Bank Name:</p>
</blockquote></td>
<td colspan="12">     </td>
<td colspan="16"></td>
</tr>
<tr class="odd">
<td colspan="29"></td>
</tr>
<tr class="even">
<td><blockquote>
<p>Address:</p>
</blockquote></td>
<td colspan="12">     </td>
<td colspan="16"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="12">     </td>
<td colspan="6">Phone #:</td>
<td colspan="9">(     )      </td>
<td></td>
</tr>
<tr class="even">
<td colspan="29"></td>
</tr>
<tr class="odd">
<td colspan="29"></td>
</tr>
<tr class="even">
<td colspan="5"><blockquote>
<p>Nine-digit Routing Transit Number: <strong>(ACH)</strong></p>
</blockquote></td>
<td> </td>
<td></td>
<td> </td>
<td></td>
<td colspan="2"> </td>
<td></td>
<td colspan="2"> </td>
<td colspan="2"></td>
<td> </td>
<td></td>
<td colspan="2"> </td>
<td colspan="2"></td>
<td> </td>
<td></td>
<td> </td>
<td></td>
<td> </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="29"></td>
</tr>
<tr class="even">
<td colspan="2"><blockquote>
<p>Account Number:</p>
</blockquote></td>
<td colspan="19">     </td>
<td colspan="8"></td>
</tr>
<tr class="odd">
<td colspan="29"></td>
</tr>
<tr class="even">
<td colspan="3"><blockquote>
<p>Type of Account:</p>
</blockquote></td>
<td></td>
<td colspan="6">Checking</td>
<td colspan="5"></td>
<td colspan="14">Savings</td>
</tr>
<tr class="odd">
<td colspan="29"></td>
</tr>
</tbody>
</table>

**TVA INFORMATION**

+--------------------+------------------------+-----------------------+
| > **EFT Contact    | **Tom Cameron**        | **Phone \# (865)      |
| > Name:**          |                        | 632-4449**            |
+--------------------+------------------------+-----------------------+
|                    | **WT 4A-K**            |                       |
+--------------------+------------------------+-----------------------+
|                    | **P.O. Box 15500**     | **Fax \# (865)        |
|                    |                        | 632-6609 OR**         |
+--------------------+------------------------+-----------------------+
|                    | **Knoxville, TN        | > **(865) 632-4019**  |
|                    | 37901-5500**           |                       |
+--------------------+------------------------+-----------------------+
|                    |                        |                       |
+--------------------+------------------------+-----------------------+
| > **Internet       | **mtcameron@tva.gov**  |                       |
| > Address:**       |                        |                       |
+--------------------+------------------------+-----------------------+