ACH VENDOR/MISCELLANEOUS PAYMENT

**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.

+-----------------------------------------------------------------------+
| # 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:               |           |           |                       |
|                       |           |           |                       |
| National Institutes   |           |           |                       |
| of Health, Office of  |           |           |                       |
| Financial Management  |           |           |                       |
+-----------------------+-----------+-----------+-----------------------+
| AGENCY IDENTIFIER:    | AGENCY    |           | ACH FORMAT:           |
|                       | LOCATION  |           |                       |
| NIH Treasury 303      | CODE      |           | CCD+ CTX CTP          |
|                       | (ALC):    |           |                       |
|                       |           |           |                       |
|                       | 7         |           |                       |
|                       | 5-08-0031 |           |                       |
|                       | or        |           |                       |
|                       | 7         |           |                       |
|                       | 5-08-0040 |           |                       |
+-----------------------+-----------+-----------+-----------------------+
| ADDRESS:              |           |           |                       |
|                       |           |           |                       |
| 31 Center Drive, MSC  |           |           |                       |
| 2045, Building 31,    |           |           |                       |
| Room B1B04            |           |           |                       |
+-----------------------+-----------+-----------+-----------------------+
| Bethesda, MD          |           |           |                       |
| 20892-2045            |           |           |                       |
+-----------------------+-----------+-----------+-----------------------+
| CONTACT PERSON NAME:  |           | TELEPHONE |                       |
|                       |           | NUMBER:   |                       |
| Sandy Thrasher        |           |           |                       |
|                       |           | \(301\)   |                       |
|                       |           | 496-5635  |                       |
|                       |           | FAX:      |                       |
|                       |           | (301)     |                       |
|                       |           | 402-1025  |                       |
+-----------------------+-----------+-----------+-----------------------+
| ADDITIONAL            |           |           |                       |
| INFORMATION:          |           |           |                       |
|                       |           |           |                       |
| Original signature    |           |           |                       |
| must be on file       |           |           |                       |
+-----------------------+-----------+-----------+-----------------------+

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

+-------------------------------------------+--------------------------+
| # FINANCIAL INSTITUTION INFORMATION       |                          |
+-------------------------------------------+--------------------------+
| NAME:                                     |                          |
|                                           |                          |
|                                           |                          |
+-------------------------------------------+--------------------------+
| ADDRESS:                                  |                          |
|                                           |                          |
|                                           |                          |
+-------------------------------------------+--------------------------+
|                                           |                          |
+-------------------------------------------+--------------------------+
| ACH COORDINATOR NAME:                     | TELEPHONE NUMBER:        |
|                                           |                          |
|                                           |                          |
+-------------------------------------------+--------------------------+
| NINE-DIGIT ROUTING TRANMIT NUMBER:        |                          |
|                                           |                          |
+-------------------------------------------+--------------------------+
| DEPOSITOR ACCOUNT TITLE:                  |                          |
|                                           |                          |
|                                           |                          |
+-------------------------------------------+--------------------------+
| DEPOSITOR ACCOUNT NUMBER:                 | LOCKBOX NUMBER:          |
|                                           |                          |
|                                           |                          |
+-------------------------------------------+--------------------------+
| TYPE OF ACCOUNT: CHECKING SAVINGS LOCKBOX |                          |
+-------------------------------------------+--------------------------+
| SIGNATURE AND TITLE OF AUTHORIZED         | TELEPHONE NUMBER:        |
| OFFICIAL:                                 |                          |
|                                           |                          |
| (Could be the same as ACH Coordinator)    |                          |
+-------------------------------------------+--------------------------+

NSN 7540-01-274-9925 381-102 SF3881 (Rev. 12/90)

Prescribed by Department of Treasury

31 USC 3322, 31 CFR 210