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<td><p><em>WAPA F 2200.56 #</em></p>
<p><em>(1-00)</em></p></td>
<td colspan="31"><p>U.S. DEPARTMENT OF ENERGY</p>
<p>WESTEREN AREA POWER ADMINISTRATION</p>
<h1 id="ach-payment-enrollment-form">ACH PAYMENT ENROLLMENT
FORM</h1></td>
<td></td>
</tr>
<tr class="even">
<td colspan="33">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.</td>
</tr>
<tr class="odd">
<td colspan="33"><strong>PRIVACY ACT STATEMENT</strong></td>
</tr>
<tr class="even">
<td colspan="33"><blockquote>
<p>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 provision 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.</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="33"></td>
</tr>
<tr class="even">
<td colspan="33"><strong>AGENCY INFORMATION</strong></td>
</tr>
<tr class="odd">
<td colspan="33"><blockquote>
<p>FEDERAL PROGRAM AGENCY:</p>
<p>Western Area Power Administration</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="4"><blockquote>
<p>AGENCY IDENTIFIER:</p>
<p>WAPA</p>
</blockquote></td>
<td colspan="21"><blockquote>
<p>AGENCY LOCATION CODE: (ALC)</p>
<p>89001602</p>
</blockquote></td>
<td colspan="8"><blockquote>
<p>ACH FORMAT:</p>
<p>CCD+</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="33"><blockquote>
<p>ADDRESS:</p>
<p>P. O. Box 281213</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="33"><blockquote>
<p>Lakewood, CO 80228-8213</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="22"><blockquote>
<p>CONTACT:</p>
</blockquote></td>
<td colspan="11"><blockquote>
<p>TELEPHONE NUMBER:</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="22"><blockquote>
<p>Fiscal Accounting, A8210</p>
</blockquote></td>
<td colspan="11"><blockquote>
<p>(720) 962-7521</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="5"><blockquote>
<p>VENDOR NO.:</p>
</blockquote></td>
<td colspan="17"><blockquote>
<p>ADDITIONAL INFORMATION:</p>
</blockquote></td>
<td colspan="11"><blockquote>
<p>FACSIMILE NUMBER:</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="5"><blockquote>
<p><strong>     </strong></p>
</blockquote></td>
<td colspan="17"><blockquote>
<p><strong>     </strong></p>
</blockquote></td>
<td colspan="11"><blockquote>
<p>(720) 962-7459</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="33"></td>
</tr>
<tr class="even">
<td colspan="33"><strong>PAYEE/COMPANY INFORMATION</strong></td>
</tr>
<tr class="odd">
<td colspan="22"><blockquote>
<p>NAME:</p>
</blockquote></td>
<td colspan="11"><blockquote>
<p>FED TAXPAYER ID OR SSN NO.: (9 DIGITS)</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="22"><blockquote>
<p><strong>     </strong></p>
</blockquote></td>
<td colspan="11"><blockquote>
<p><strong>     </strong></p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="33"><blockquote>
<p>ADDRESS:</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="33"><blockquote>
<p><strong>     </strong></p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="33"><blockquote>
<p><strong>     </strong></p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="22"><blockquote>
<p>CONTACT PERSON: (NAME, TITLE, AND SIGNATURE)</p>
</blockquote></td>
<td colspan="11">TELEPHONE NUMBER:</td>
</tr>
<tr class="odd">
<td colspan="22"><blockquote>
<p><strong>     </strong></p>
</blockquote></td>
<td colspan="11">(<strong>   </strong>) <strong>     </strong></td>
</tr>
<tr class="even">
<td colspan="33"></td>
</tr>
<tr class="odd">
<td colspan="33"><strong>FINANCIAL INSTITUTION INFORMATION</strong></td>
</tr>
<tr class="even">
<td colspan="33"><blockquote>
<p>NAME:</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="33"><blockquote>
<p><strong>     </strong></p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="33"><blockquote>
<p>ADDRESS:</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="33"><blockquote>
<p><strong>     </strong></p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="33"><blockquote>
<p><strong>     </strong></p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="22"><blockquote>
<p>ACH COORDINATOR NAME:</p>
</blockquote></td>
<td colspan="11">TELEPHONE NUMBER:</td>
</tr>
<tr class="even">
<td colspan="22"><blockquote>
<p><strong>     </strong></p>
</blockquote></td>
<td colspan="11">(<strong>   </strong>) <strong>     </strong></td>
</tr>
<tr class="odd">
<td colspan="6"><blockquote>
<p>NINE-DIGIT ROUTING TRANSIT NUMBER: (ABA)</p>
</blockquote></td>
<td></td>
<td colspan="3"><blockquote>
<p><strong> </strong></p>
</blockquote></td>
<td></td>
<td><blockquote>
<p><strong> </strong></p>
</blockquote></td>
<td></td>
<td><blockquote>
<p><strong> </strong></p>
</blockquote></td>
<td></td>
<td><blockquote>
<p><strong> </strong></p>
</blockquote></td>
<td></td>
<td><blockquote>
<p><strong> </strong></p>
</blockquote></td>
<td></td>
<td colspan="2"><blockquote>
<p><strong> </strong></p>
</blockquote></td>
<td colspan="3"></td>
<td colspan="2"><blockquote>
<p><strong> </strong></p>
</blockquote></td>
<td></td>
<td colspan="2"><blockquote>
<p><strong> </strong></p>
</blockquote></td>
<td></td>
<td><blockquote>
<p><strong> </strong></p>
</blockquote></td>
<td colspan="2"></td>
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</tr>
<tr class="odd">
<td colspan="33"><blockquote>
<p>DEPOSITOR ACCOUNT TITLE:</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="33"><blockquote>
<p><strong>     </strong></p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="33"><blockquote>
<p>DEPOSITOR ACCOUNT NUMBER:</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="33"><blockquote>
<p><strong>     </strong></p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="33"><blockquote>
<p>TYPE OF ACCOUNT:</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td><blockquote>
&#10;</blockquote></td>
<td colspan="5"><blockquote>
<p>CHECKING</p>
</blockquote></td>
<td colspan="3"><blockquote>
&#10;</blockquote></td>
<td colspan="22"><blockquote>
<p>SAVINGS</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="23"><blockquote>
<p>SIGNATURE AND TITLE OF AUTHORIZED OFFICIAL:</p>
<p>(Could be the same as ACH Coordinator)</p>
</blockquote></td>
<td colspan="10"><blockquote>
<p>TELEPHONE NUMBER:</p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="23"></td>
<td colspan="10"><blockquote>
<p>(   )      </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="9"><blockquote>
<p> AGENY COPY</p>
</blockquote></td>
<td colspan="19"><blockquote>
<p> PAYEE COMPANY COPY</p>
</blockquote></td>
<td colspan="5"><blockquote>
<p> FINANCIAL INSTITUTION COPY</p>
</blockquote></td>
</tr>
</tbody>
</table>