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U.S. Geological Survey Manual

Attachment 4


Office Letterhead


Company Name
Company Address

Dear Sirs:

The Debt Collection Improvement Act requires most Federal payments to be made electronically beginning January 2, 1999. This Act also requires payments to include the taxpayer identification number (TIN). The TIN is usually an individual's social security number.

We do not have the information checked below to pay your invoice _______________________________ dated__________________.

The Debt Collection Improvement Act allows for waivers to the electronic payment requirement in certain instances. If the first box above was checked and you believe you meet the requirements to receive a waiver, please sign the statement below and return this form to the above address.

Payment by electronic funds transfer would impose a hardship due to a physical or mental disability or a geographic, language, or literary barrier, or would impose a financial hardship.

_______________________ ________________________
Signature / Date

image of a internal use block showing vendor code, doc number, approved line and date

1 Payment Enrollment Form
2 Invoice ___________

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U.S. Geological Survey, 807 National Center, Reston, VA 20192, USA
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Last modification: 11-Jan-2013@10:57(bt)