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 

AGENCY IDENTIFIER: AGENCY LOCATION CODE (ALC): ACH FORMAT: 

CCD+ CTX 

ADDRESS: 

CONTACT PERSON NAME: TELEPHONE NUMBER: 

( ) 

ADDITIONAL INFORMATION: 

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 TRANSIT NUMBER: 

DEPOSITOR ACCOUNT TITLE: 

( ) 

DEPOSITOR ACCOUNT NUMBER: LOCKBOX NUMBER: 

TYPE OF ACCOUNT: 

CHECKING SAVINGS LOCKBOX 

SIGNATURE AND TITLE OF AUTHORIZED OFFICIAL: TELEPHONE NUMBER: 

(Could be the same as ACH Coordinator) 

( ) 

SF 3881 (Rev. 2/2003 ) AUTHORIZED FOR LOCAL REPRODUCTION Prescribed by Department of Treasury 

31 U S C 3322; 31 CFR 210 
Instructions for Completing SF 3881 Form 

Make three copies of form after completing. Copy 1 is the Agency Copy; copy 2 is the 

Payee/Company Copy; and copy 3 is the Financial Institution Copy. 

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 

The 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.