**ACH VENDOR/MISCELLANEOUS PAYMENT** OMB No. 1510‑0056

**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. See reverse for additional
instructions.

+-----------------------------------------------------------------------+
| **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           |                        |      |                  |
|                  |                        |      |                  |
| #                |                        |      |                  |
| U.S. Department  |                        |      |                  |
| of Energy, Natio |                        |      |                  |
| nal Energy Techn |                        |      |                  |
| ology Laboratory |                        |      |                  |
+------------------+------------------------+------+------------------+
| AGENCY           | AGENCY LOCATION CODE   | ACH  |                  |
| IDENTIFIER:      | (ALC):                 | FO   |                  |
|                  |                        | RMAT |                  |
| **N              | **89000001**           |      |                  |
| ETL-Pittsburgh** |                        | C    |                  |
|                  |                        | CD + |                  |
|                  |                        | CTX  |                  |
|                  |                        | CTP  |                  |
+------------------+------------------------+------+------------------+
| ADDRESS:         |                        |      |                  |
|                  |                        |      |                  |
| # P.O. Box 10940 |                        |      |                  |
+------------------+------------------------+------+------------------+
| **Pittsburgh, PA |                        |      |                  |
| 15236-0940**     |                        |      |                  |
+------------------+------------------------+------+------------------+
| CONTACT PERSON   |                        |      | TELEPHONE        |
| NAME:            |                        |      | NUMBER:          |
|                  |                        |      |                  |
| #                |                        |      | **(412)          |
| Jeannine Walbert |                        |      | 386-5710**       |
+------------------+------------------------+------+------------------+
| ADDITIONAL       |                        |      |                  |
| INFORMATION:     |                        |      |                  |
|                  |                        |      |                  |
| **Award Number:  |                        |      |                  |
| DE-     **       |                        |      |                  |
+------------------+------------------------+------+------------------+

+---------------------------------------------------+------------------+
| **PAYEE/COMPANY INFORMATION**                     |                  |
+---------------------------------------------------+------------------+
| NAME                                              | SSN NO. OR       |
|                                                   | TAXPAYER ID NO.  |
| **     **                                         |                  |
|                                                   | **     **        |
+---------------------------------------------------+------------------+
| ADDRESS                                           |                  |
|                                                   |                  |
| **     **                                         |                  |
+---------------------------------------------------+------------------+
|                                                   |                  |
+---------------------------------------------------+------------------+
| CONTACT PERSON NAME:                              | TELEPHONE        |
|                                                   | NUMBER:          |
| **     **                                         |                  |
|                                                   | **(     )        |
|                                                   |      **          |
+---------------------------------------------------+------------------+

+-----------------+---------------------------------+---+--------------+
| **FINANCIAL     |                                 |   |              |
| INSTITUTION     |                                 |   |              |
| INFORMATION**   |                                 |   |              |
+-----------------+---------------------------------+---+--------------+
| NAME:           |                                 |   |              |
|                 |                                 |   |              |
| **     **       |                                 |   |              |
+-----------------+---------------------------------+---+--------------+
| ADDRESS:        |                                 |   |              |
|                 |                                 |   |              |
| **     **       |                                 |   |              |
+-----------------+---------------------------------+---+--------------+
| **     **       |                                 |   |              |
+-----------------+---------------------------------+---+--------------+
| ACH COORDINATOR |                                 | T |              |
| NAME:           |                                 | E |              |
|                 |                                 | L |              |
| **     **       |                                 | E |              |
|                 |                                 | P |              |
|                 |                                 | H |              |
|                 |                                 | O |              |
|                 |                                 | N |              |
|                 |                                 | E |              |
|                 |                                 | N |              |
|                 |                                 | U |              |
|                 |                                 | M |              |
|                 |                                 | B |              |
|                 |                                 | E |              |
|                 |                                 | R |              |
|                 |                                 | : |              |
|                 |                                 |   |              |
|                 |                                 | ( |              |
|                 |                                 | * |              |
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|                 |                                 |   |              |
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|                 |                                 | ) |              |
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|                 |                                 |   |              |
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|                 |                                 |   |              |
|                 |                                 |   |              |
|                 |                                 | * |              |
|                 |                                 | * |              |
+-----------------+---------------------------------+---+--------------+
| NINE-DIGIT      |                                 |   |              |
| ROUTING TRANSIT |                                 |   |              |
| NUMBER:         |                                 |   |              |
|                 |                                 |   |              |
| **[             |                                 |   |              |
|   ]{.underline} |                                 |   |              |
| [               |                                 |   |              |
|   ]{.underline} |                                 |   |              |
| [               |                                 |   |              |
|   ]{.underline} |                                 |   |              |
| [               |                                 |   |              |
|   ]{.underline} |                                 |   |              |
| [               |                                 |   |              |
|   ]{.underline} |                                 |   |              |
| [               |                                 |   |              |
|   ]{.underline} |                                 |   |              |
| [               |                                 |   |              |
|   ]{.underline} |                                 |   |              |
| [               |                                 |   |              |
|   ]{.underline} |                                 |   |              |
| [               |                                 |   |              |
| ]{.underline}** |                                 |   |              |
+-----------------+---------------------------------+---+--------------+
| DEPOSITOR       |                                 |   |              |
| ACCOUNT TITLE:  |                                 |   |              |
|                 |                                 |   |              |
| **     **       |                                 |   |              |
+-----------------+---------------------------------+---+--------------+
| DEPOSITOR       |                                 |   | LOCKBOX      |
| ACCOUNT NUMBER: |                                 |   | NUMBER:      |
|                 |                                 |   |              |
|                 |                                 |   | **     **    |
+-----------------+---------------------------------+---+--------------+
| TYPE OF         | CHECKING SAVINGS LOCKBOX        |   |              |
| ACCOUNT:        |                                 |   |              |
+-----------------+---------------------------------+---+--------------+
| SIGNATURE AND   |                                 | T |              |
| TITLE OF        |                                 | E |              |
| AUTHORIZED      |                                 | L |              |
| OFFICIAL:       |                                 | E |              |
|                 |                                 | P |              |
| (Could be the   |                                 | H |              |
| same as ACH     |                                 | O |              |
| Coordinator)    |                                 | N |              |
|                 |                                 | E |              |
|                 |                                 | N |              |
|                 |                                 | U |              |
|                 |                                 | M |              |
|                 |                                 | B |              |
|                 |                                 | E |              |
|                 |                                 | R |              |
|                 |                                 | : |              |
|                 |                                 |   |              |
|                 |                                 | ( |              |
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|                 |                                 |   |              |
|                 |                                 | * |              |
|                 |                                 | * |              |
|                 |                                 | ) |              |
|                 |                                 | * |              |
|                 |                                 | * |              |
|                 |                                 |   |              |
|                 |                                 |   |              |
|                 |                                 |   |              |
|                 |                                 |   |              |
|                 |                                 |   |              |
|                 |                                 | * |              |
|                 |                                 | * |              |
+-----------------+---------------------------------+---+--------------+

**AUTHORIZED FOR LOCAL REPRODUCTION** SF 3881# (Rev 2/2003)

Prescribed by Department of Treasury

31 U S C 3322; 31 CFR 210

## Instructions for Completing SF 3881 Form

1\. Agency Information Section ‑ Federal agency prints or types the name
and address of the Federal program agency originating the
vendor/miscellaneous payment, agency identifier, agency location code,
contact person name and telephone number of the agency. Also, the
appropriate box for ACH format is checked.

2\. Payee/Company Information Section ‑ Payee prints or types the name
of the payee/company and address that will receive ACH
vendor/miscellaneous payments, social security or taxpayer ID number,
and contact person name and telephone number of the payee/company. Payee
also verifies depositor account number, account title, and type of
account entered by your financial institution in the Financial
Institution Information Section.

3\. Financial Institution Information Section ‑ Financial institution
prints or types the name and address of the payee/companys financial
institution who will receive the ACH payment, ACH coordinator name and
telephone number, nine-digit routing transit number, depositor
(payee/company) account title and account number. Also, the box for type
of account is checked, and the signature, title, and telephone number of
the appropriate financial institution official are included.

## Burden Estimate Statement

Number range CHAPTERThe estimated average burden associated with this
collection of information is 15 minutes per respondent or recordkeeper,
depending on individual circumstances. Comments concerning the accuracy
of this burden estimate and suggestions for reducing this burden should
be directed to the Financial Management Service, Facilities Management
Division, Property and Supply Branch, Room B-101, 3700 East West
Highway, Hyattsville, MD 20782 and the Office of Management and Budget,
Paperwork Reduction Project (1510-0056), Washington, DC 20503.