Common use of Privacy Act Statement Clause in Contracts

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. FEDERAL PROGRAM AGENCY AGENCY IDENTIFIER: AGENCY LOCATION CODE (ALC): ACH FORMAT: CCD+ CTX ADDRESS: CONTACT PERSON NAME: TELEPHONE NUMBER: ( ) ADDITIONAL INFORMATION: NAME SSN NO. OR TAXPAYER ID NO. ADDRESS CONTACT PERSON NAME: TELEPHONE NUMBER: ( ) 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: (Could be the same as ACH Coordinator) TELEPHONE NUMBER: ( ) AUTHORIZED FOR LOCAL REPRODUCTION SF 3881 (Rev. 2/2003 ) Prescribed by Department of Treasury 31 U S C 3322; 31 CFR 210 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.

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. FEDERAL PROGRAM AGENCY AGENCY IDENTIFIER: AGENCY LOCATION CODE (ALC): ACH FORMAT: CCD+ CTX ADDRESS: CONTACT PERSON NAME: TELEPHONE NUMBER: ( ) ADDITIONAL INFORMATION: NAME SSN NO. OR TAXPAYER ID NO. ADDRESS CONTACT PERSON NAME: TELEPHONE NUMBER: ( ) 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: (Could be the same as ACH Coordinator) TELEPHONE NUMBER: ( ) AUTHORIZED FOR LOCAL REPRODUCTION SF 3881 (Rev. 2/2003 ) Prescribed by Department of Treasury 31 U S C 3322; 31 CFR 210 Make three copies of form after completing. Copy 1 is the Agency Copy; copy 2 is the Payee/Payee/ Company Copy; and copy 3 is the Financial Institution Copy.

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. FEDERAL PROGRAM AGENCY Federal Motor Carrier Safety Administration AGENCY IDENTIFIER: n/a AGENCY LOCATION CODE (ALC): n/a ACH FORMAT: CCD+ CTX ADDRESS: 0000 Xxx Xxxxxx Xxxxxx XX, Xxxxxxxxxx, XX 00000 CONTACT PERSON NAME: Xxxxxxx Xxxxxxxx, MC-MBF TELEPHONE NUMBER: ( 000 ) 000-0000 ADDITIONAL INFORMATION: GRANTEE: ENTER Number from Block 2 of Agreement: PO# FM- NAME SSN NO. OR TAXPAYER ID NO. ADDRESS CONTACT PERSON NAME: TELEPHONE NUMBER: ( ) 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: (Could be the same as ACH Coordinator) DATE TELEPHONE NUMBER: ( ) AUTHORIZED FOR LOCAL REPRODUCTION ***FAX THE COMPLETED FORM TO 000-000-0000*** SF 3881 (Rev. 2/2003 ) Prescribed by Department of Treasury 31 U S C 3322; 31 CFR 210 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.

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. FEDERAL PROGRAM AGENCY Delta Regional AGENCY IDENTIFIER: AGENCY LOCATION CODE (ALC): ACH FORMAT: CCD+ CTX ADDRESS: 000 Xxxxxxx Xxxxxx, Suite 400 Clarksdale, MS 38614 CONTACT PERSON NAME: Xxxxxxx Xxxxxx TELEPHONE NUMBER: ( 000 ) 000-0000 ADDITIONAL INFORMATION: NAME SSN NO. OR TAXPAYER ID NO. ADDRESS CONTACT PERSON NAME: TELEPHONE NUMBER: ( ) 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: (Could be the same as ACH Coordinator) TELEPHONE NUMBER: ( ) AUTHORIZED FOR LOCAL REPRODUCTION SF 3881 (Rev. 2/2003 ) Prescribed by Department of Treasury 31 U S C 3322; 31 CFR 210 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.