VOLPE NATIONAL TRANSPORTATION SYSTEMS CENTER

# VENDOR PAYMENT DATA FORM

+-----------------------+-----------+-------+---+-----------------------+
| **IMPORTANT**: To     |           |       |   |                       |
| facilitate and help   |           |       |   |                       |
| ensure prompt         |           |       |   |                       |
| payment, please       |           |       |   |                       |
| complete the          |           |       |   |                       |
| information below and |           |       |   |                       |
| return immediately    |           |       |   |                       |
| to:                   |           |       |   |                       |
|                       |           |       |   |                       |
| ACCOUNTS PAYABLE      |           |       |   |                       |
| DTS-823               |           |       |   |                       |
|                       |           |       |   |                       |
| VOLPE CENTER TEL      |           |       |   |                       |
| VOICE 617/494-2141    |           |       |   |                       |
|                       |           |       |   |                       |
| 55 BROADWAY TEL FAX   |           |       |   |                       |
| 617/494-3068          |           |       |   |                       |
|                       |           |       |   |                       |
| CAMBRIDGE, MA         |           |       |   |                       |
| 02142-1093            |           |       |   |                       |
+-----------------------+-----------+-------+---+-----------------------+
| ##                    |           |       |   |                       |
| PRIVACY ACT STATEMENT |           |       |   |                       |
|                       |           |       |   |                       |
| The following         |           |       |   |                       |
| information is        |           |       |   |                       |
| provided to comply    |           |       |   |                       |
| with the Privacy Act  |           |       |   |                       |
| of 1974 (P.L.         |           |       |   |                       |
| 93---579). The vendor |           |       |   |                       |
| information and       |           |       |   |                       |
| financial information |           |       |   |                       |
| is required under the |           |       |   |                       |
| provisions of 31 CFR  |           |       |   |                       |
| 210. This information |           |       |   |                       |
| will be used by the   |           |       |   |                       |
| Treasury Department   |           |       |   |                       |
| to transmit payment   |           |       |   |                       |
| data 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. |           |       |   |                       |
+-----------------------+-----------+-------+---+-----------------------+
| ## VENDOR INFORMATION |           |       |   |                       |
+-----------------------+-----------+-------+---+-----------------------+
| NAME:                 |           |       |   |                       |
+-----------------------+-----------+-------+---+-----------------------+
| ADDRESS:              |           |       |   |                       |
+-----------------------+-----------+-------+---+-----------------------+
| REMIT TO ADDRESS IF   |           |       |   |                       |
| DIFFERENT:            |           |       |   |                       |
+-----------------------+-----------+-------+---+-----------------------+
| ACCOUNTS RECEIVABLE   |           |       | T |                       |
| CONTACT PERSON:       |           |       | E |                       |
|                       |           |       | L |                       |
|                       |           |       | E |                       |
|                       |           |       | P |                       |
|                       |           |       | H |                       |
|                       |           |       | O |                       |
|                       |           |       | N |                       |
|                       |           |       | E |                       |
|                       |           |       | N |                       |
|                       |           |       | U |                       |
|                       |           |       | M |                       |
|                       |           |       | B |                       |
|                       |           |       | E |                       |
|                       |           |       | R |                       |
|                       |           |       | : |                       |
+-----------------------+-----------+-------+---+-----------------------+
| ## FINANCIAL IN       |           |       |   |                       |
| STITUTION INFORMATION |           |       |   |                       |
+-----------------------+-----------+-------+---+-----------------------+
| BANK NAME:            |           |       |   |                       |
+-----------------------+-----------+-------+---+-----------------------+
| ADDRESS:              |           |       |   |                       |
+-----------------------+-----------+-------+---+-----------------------+
| ACH COORDINATOR NAME: |           |       | T |                       |
|                       |           |       | E |                       |
|                       |           |       | L |                       |
|                       |           |       | E |                       |
|                       |           |       | P |                       |
|                       |           |       | H |                       |
|                       |           |       | O |                       |
|                       |           |       | N |                       |
|                       |           |       | E |                       |
|                       |           |       | N |                       |
|                       |           |       | U |                       |
|                       |           |       | M |                       |
|                       |           |       | B |                       |
|                       |           |       | E |                       |
|                       |           |       | R |                       |
+-----------------------+-----------+-------+---+-----------------------+
| ACCOUNT HOLDER NAME:  |           |       |   |                       |
+-----------------------+-----------+-------+---+-----------------------+
| ACCOUNT TYPE:         |           |       |   |                       |
| CHECKING SAVINGS (If  |           |       |   |                       |
| unclear, check with   |           |       |   |                       |
| your bank)            |           |       |   |                       |
+-----------------------+-----------+-------+---+-----------------------+
| ACH ROUTING TRANSIT   |           |       |   |                       |
| NUMBER (9-DIGIT):     |           |       |   |                       |
+-----------------------+-----------+-------+---+-----------------------+
| ACCOUNT NUMBER:       |           |       |   |                       |
+-----------------------+-----------+-------+---+-----------------------+
| **TAXPAYER            |           |       |   |                       |
| IDENTIFICATION NUMBER |           |       |   |                       |
| (enter one only)**    |           |       |   |                       |
+-----------------------+-----------+-------+---+-----------------------+
| TAX IDENTIFICATION    |           |       |   |                       |
| NUMBER (TIN):         |           |       |   |                       |
+-----------------------+-----------+-------+---+-----------------------+
| SOCIAL SECURITY       |           |       |   |                       |
| NUMBER:               |           |       |   |                       |
+-----------------------+-----------+-------+---+-----------------------+
| CONTRACT/P.O.:        |           |       |   |                       |
+-----------------------+-----------+-------+---+-----------------------+
| ISSUE IRS FORM 1099:  |           |       |   |                       |
| YES NO                |           |       |   |                       |
+-----------------------+-----------+-------+---+-----------------------+
| 1099 ADDRESS (If      |           |       |   |                       |
| different):           |           |       |   |                       |
+-----------------------+-----------+-------+---+-----------------------+
| CITY:                 | STATE:    |       |   | ZIP:                  |
+-----------------------+-----------+-------+---+-----------------------+
| ### FOR COMPLETIO     |           |       |   |                       |
| N BY ACOUNTING BRANCH |           |       |   |                       |
+-----------------------+-----------+-------+---+-----------------------+
| VENDOR TYPE:          |           |       |   |                       |
|                       |           |       |   |                       |
| 2 DOMESTIC            |           |       |   |                       |
| TRANSPORTATION        |           |       |   |                       |
|                       |           |       |   |                       |
| 3 VENDOR              |           |       |   |                       |
| (CONTRACTS/GOODS/SVS) |           |       |   |                       |
|                       |           |       |   |                       |
| 9 FOREIGN OTHER       |           |       |   |                       |
+-----------------------+-----------+-------+---+-----------------------+
| T-16 VENDOR TYPE/SSN, |           |       |   |                       |
| IF DIFFERENT:         |           |       |   |                       |
+-----------------------+-----------+-------+---+-----------------------+
| T-16: ADDED CHANGED   |           |       |   |                       |
| FOD VERIFIED          |           |       |   |                       |
+-----------------------+-----------+-------+---+-----------------------+
| NAME:                 |           | DATE: |   |                       |
+-----------------------+-----------+-------+---+-----------------------+

VNTSC F 4250.2 (01/97) FAR 52.232-33 FAR 52.204-3 OPI: 823