U.S. Geological Survey
(From the back of form)
This form should be completed by contractors and vendors who have been awarded a USGS contract or purchase order, but are exempt from the requirement to register in CCR.
1. Agency Information Section - Payee enters contract or purchase order number and DUNS number in the blocks provided. If unknown, Payee should consult their USGS Contracting Officer.
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 boxes for type of account and ACH format are checked, and the signature, title and telephone number of the appropriate financial institution official are included.