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EFT Information Request Form. This is a Official Federal Forms form and can be use in US Copyright Office.
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EFT INFORMATION REQUEST CEC / DUNS Number +Four SSN / TIN VENDOR TYPE 1. Employee TYPE OF BUSINESS 1. Small Disadvantaged Business 2. Other Small Business 3. Large Business 4. Sheltered Workshop 5. Nonprofit Educational Organization 6. Nonprofit Hospital Name of Business or Individual Primary Contact Name Financial Contact Name SIC CODE Licensing Division - United States Copyright Office TEL (202)707-8150 - FAX (202)707-0905 - www.copyright.gov/licensing Corporations or partnerships use Federal Taxpayer Identification Number (TIN) Independent contractors or sole proprietors use Social Security Number (SSN) Non-Foreign firms without TIN, do not enter number 2. Federal 7. Other Nonprofit Organization 8. State/Local Government Education 9. State/Local Government Hospital 10. Other State/Local Government 11. Federal Government - Non Dept. 3. Nonfederal 13. Federal Government - Within Bureau 14. Foreign Contractor 15. Domestic Contractor 16. Woman Owned Business 17. Minority Owned Business 12. Federal Government - Within Dept. 18. Emerging Small Business Alternate Name/Doing Business As Telephone Number Telephone Number E-mail Address E-mail Address PRIMARY BUSINESS PRODUCT MAILING ADDRESS Address City Telephone Number Address City Telephone Number Financial Institution Name Account Number City Account Title (if different than name of business or individual) CERTIFICATION OF INFORMATION I understand that the Library of Congress will make payments by ACH financial institution information. Title/Position Telephone Number Date FOR LICENSING DIVISION ONLY Legal Name (As on statement of account) ID# Period Type State Fax Number ACH FINANCIAL INSTITUTION INFORMATION Routing/ABA Number Corporate Checking Lockbox Personal Checking Savings Zip Code Country State Zip Code Fax Number REMITTANCE ADDRESS (complete only if different than the address above) State Zip Code TYPE Name Signature Privacy Act Notice: Section 111, section 119 and chapter 10 of title 17, United States Code, authorizes the Copyright Office to collect the personally identifying information (PII) requested on this form. PII is any personal information that can be used to identify or contact an individual, such as names, addresses and telephone numbers. The Copyright Office collects this PII in order to process your refund. By providing your PII, you are agreeing to the routine use of it for this purpose. The effects of not providing the PII requested here is that it may delay sending your refund. 1819 (2015/05) American LegalNet, Inc. www.FormsWorkFlow.com