Obrazac 3881-A

Obrazac 3881-A (Rev. 5-2017)

ACH dobavljač/upis za razna plaćanja - HCTC

This document is instructions for completing Form 3881-A, used for establishing Automated Clearing House (ACH) payments with an addendum record processed through the Direct Deposit Program. It includes sections for agency information, payee/company information, and financial institution information. The agency information section contains the name and address of the Federal program agency originating the vendor/miscellaneous payments, agency identifier, location code, contact person name and telephone number, and ACH format. The payee/company information section includes the name and address of the payee or Health Plan Administrator (HPA), social security or taxpayer ID number, contact person and telephone number, and verification of depositor account number and type of account. The financial institution information section includes the name and address of the payee/company's financial institution, ACH coordinator name and telephone number, nine-digit routing transit number, depositor account number, and type of account. The signature, title, and telephone number of the appropriate financial institution official is also required.