######  **Treasury T-CORE Contact Information for**

####### Electronic Summary of Debt Statement

**Please complete this form and submit it in one of three ways:**

**1. FAX: Treasury Check Operations Reengineering Effort**

> **(T-CORE) at (804) 697-2607**

##### 2. Mail: Federal Reserve Bank of Richmond

> **Electronic Payment Department**
>
> **T-CORE Operation "C" Level**
>
> **P.O. Box 85111**
>
> **Richmond, VA 23285**

**3. E-mail this information to: <CORE@RICH.FRB.ORG>**

+-----------------------------+-----------------------------------------+
| ## Please print legibly or  |                                         |
|  type the information below |                                         |
+-----------------------------+-----------------------------------------+
| **1. Bank Routing/Transit   |                                         |
| Number**                    |                                         |
+-----------------------------+-----------------------------------------+
| **2. Bank Name**            |                                         |
+-----------------------------+-----------------------------------------+
| **3. Bank Address**         |                                         |
+-----------------------------+-----------------------------------------+
| **4. Taxpayer ID Number     |                                         |
| (TIN)**                     |                                         |
+-----------------------------+-----------------------------------------+
| **5. Treasury Check         |                                         |
| Reclamation**               |                                         |
|                             |                                         |
| **primary contact name**    |                                         |
+-----------------------------+-----------------------------------------+
| **6. Primary phone number** |                                         |
+-----------------------------+-----------------------------------------+
| **7. Primary e-mail         |                                         |
| address**                   |                                         |
+-----------------------------+-----------------------------------------+
| **8. Secondary Treasury     |                                         |
| Check Reclamation contact   |                                         |
| name**                      |                                         |
+-----------------------------+-----------------------------------------+
| **9. Secondary phone        |                                         |
| number**                    |                                         |
+-----------------------------+-----------------------------------------+
| **10. Secondary e-mail      |                                         |
| address**                   |                                         |
+-----------------------------+-----------------------------------------+
| # 11. Optional - FAX        |                                         |
|  Number (including area cod |                                         |
| e) if you do not have the c |                                         |
| apability to receive e-mail |                                         |
+-----------------------------+-----------------------------------------+

Completed by (Name and Title):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

####### Phone #: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_