For internal use only



### FELLOWSHIP STIPEND PAYMENT
ENROLLMENT FORM

PRIVACY ACT STATEMENT

The following information is provided to comply with the Pr ivacy Act of 1974 (P.L. 93-579). All information collected on this form is required under the provisi ons of 31 U.S.C. 3322 and 31 CFR 210. Th is information will be used by the Treasury Department to transmit payment data, by electronic mean s 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.



### EPA INFORMATION

FEDERAL PROGRAM AGENCY U.S. ENVIRONMENTAL PROTECTION AGENCY

AGENCY IDENTIFIER: LVFC AGENCY LOCATION CODE (ALC): 68128933

ADDRESS: PO BOX 98515

LAS VEGAS, NV 89193-8515

CONTRACT PERSON NAME: LUIS E RIVERA EMAIL: Rivera.LuisE@EPA.GOV TELEPHONE NUMBER (702) 798-2495

ADDITIONAL INFORMATION FAX NUMBER (702) 798-2423

FELLOW’S INFORMATION

NAME SOCIAL SECURITY NUMBER

ASSISTANCE ID/FELLOWSHIP NUMBER

ADDRESS

CONTACT PERSON EMAIL ADDRESS: TELEPHONE NUMBER: ( )

FELLOW’S BANK INFORMATION (STIPEND WILL BE SENT TO YOUR BANK BY EFT)

BANK NAME:

BANK ADDRESS:

NINE-DIGIT ROUTING TRANSIT NUMBER:

NAME ON ACCOUNT:

ACCOUNT NUMBER:

TYPE OF ACCOUNT:
CHECKING SAVINGS

FELLOW’S AUTHORIZING SIGNATURE: TELEPHONE NUMBER:

( )

EPA 190-F-05-001 OMB Control No. 20 30

- 0020 Approval expires 04 / 30 / 2012 United States
ENVIRONMENTAL PROTECTION AGENCY Washington, DC 20460NOTE: The intention of this form is to establish Direct Deposit for Stipends payable to Fellowship recipients. This is not a mandatory requirement but highly recommended. If you don’t have a bank account - DO NOT FILL OUT THIS FORM
, instead your Stipend will be forwarded by check via mail.

Instructions for the Fellowship Stipend Payment Enrollment Form:

Under FELLOW’S INFORMATION :

- Enter your name

- Enter your Social Security Number

- Enter your Assistance ID/Fellowship Number (it usually star ts with U, FP or MA, located on the top center of your Fellowship Agreement)

- Enter your mailing address

- Enter your email address

- Enter your telephone number

Under FELLOW’S BANK INFORMATION :

- Enter your banking institutions name

- Enter your banking institutions complete address (local bank address only)

- Enter your nine-digit routing number (see illustration)

- Enter the name the account is under (your name or parents, etc.)

- Enter your bank account number (see illustration)

- Enter what type of account (Checking or Savings)

- Enter signature and telephone number

Routing Number Acct Number Do not use

(Do not use the numbers from a deposit slip)

EPA 190-F-05-001 The public reporting and recordkeeping burden for this collection of information is estimated to average 30 minutes per response. Send comments on the Agency's need for this information, the accuracy of the provided burden estimates, and any suggested methods for minimizing respondent burden, including through the use of automated collection techniques to the Director, Collection Strategies Division, U.S. Environmental Protection Agency (2822T), 1200 Pennsylvania Ave., NW, Washington, D.C. 20460. Include the OMB control number in any correspondence. Do not send the completed form to this address.