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["FORM INFORMATION"]
["Form Name / Title","ACH Vendor/Miscellaneous Payment Enrollment Form"]
["Form ID",666]
["Form Version",2]
["OMB Control Number ","1530-0069"]
["OMB Expiration Date ","08/31/2025"]
["Form Family\n(select all that apply)","X","SF-424 Family"]
[null,null,"SF-424 R&R Family"]
[null,null,"SF-424 Individual Family"]
[null,null,"SF-424 Mandatory Family"]
[null,null,"SF-424 Short Organizational Family"]

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["FORM TITLE:",null,"ACH Vendor/Miscellaneous Payment Enrollment Form"]
["[1]","[2]\n","[3]\n","[4]\n","[5]\n","[6]\n","[7]\n","[8]\n","[9]","[10]\n","[11]\n","[12]","[13]","[14]","[15]\n","[16]\n","[17]\n","[18]\n","[19]\n"]
["Field #","Field\nLabel","Field ID","Required?","Minimum\nOccurrences","Maximum\nOccurrences","Agency Field\nName","Field Type","Global Library\nField Name","Field Type\nSource","Business Rules","Data Type","List of\nValues","Min  # of Chars or\nMin Value","Max # of\nChars or\nMax Value","Field\nImplementation","Help Tip","Mandatory Message ","Validation Message"]
["0-0","ACH VENDOR/MISCELLANEOUS PAYMENT ENROLLMENT FORM","Form Title Text",{"$nulls":7},"This label will appear on every page.",{"$nulls":4},"Label"]
["0-1","OMB Number: 1530-0069","OMB Number Text",{"$nulls":12},"Label"]
["0-2","Expiration Date: 08/31/2025","Expiration Date Text ",{"$nulls":12},"Label"]
["1-0","This form is used for Automated Clearing House (ACH) payments with an addendum record that contains payment-related information processed through the Vendor Express Program.  Recipients of these payments should bring this information to the attention of their financial institution when presenting this form for completion.  See reverse for additional instructions.","instructions Text",{"$nulls":12},"Label"]
["2-0","PRIVACY ACT STATEMENT","Privacy Act Statement Header",{"$nulls":12},"Label"]
["2-1","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.","Privacy Act Statement Text",{"$nulls":12},"Label"]
["3-00","AGENCY INFORMATION","Agency Information Header",{"$nulls":12},"Label"]
["3-01","Agency Name:","Agency Name","Yes","1","1","AgencyName","Pre-populated","globLib:AgencyNameDataType","SubmissionDef.AgencyName",null,"AN",null,1,60,"Field","Pre-populated from the Application cover sheet."]
["3-02","Agency Identifier:","Agency Identifier","No","0","1","AgencyIdentifier","Agency-specific",null,null,null,"AN",null,"0",12,"Field","To be completed by Agency."]
["3-03","Agency Location Code (ALC):","Agency Location Code","No","0","1","AgencyLocation","Agency-specific",null,null,"Numeric digits only","AN",null,"0",12,"Field","To be completed by Agency.",null,"Invalid Agency Location Code: To be completed by Agency."]
["3-04","ACH Format:","ACH Format","No",0,1,"ACHFormat","Radio Group",null,"ACH Format",null,"LIST",null,null,null,"Radio Group","To be completed by Agency."]
["3-04-1","CCD+","CCD+ ","No","0","1",null,"Radio Group",null,"ACH Format",{"$nulls":5},"Radio","Click to select option."]
["3-04-2","CTX","CTX ","No","0","1",null,"Radio Group",null,"ACH Format",{"$nulls":5},"Radio","Click to select option."]
["3-05","Address:\n","Agency Address Header","No",0,1,"AgencyAddress","Global","globLib:AddressDataType",{"$nulls":6},"Label"]
["3-06","Street1:","Agency Street1","No",0,1,"Street1","Global","globLib:Street1",null,"Required if any values entered for AgencyAddress","AN",null,0,55,"Field","To be completed by Agency.","Street1 is required: To be completed by Agency."]
["3-07","Street2:","Agency Street2","No",0,1,"Street2","Global","globLib:Street2",null,null,"AN",null,0,55,"Field","To be completed by Agency."]
["3-08","City:","Agency City","No",0,1,"City","Global","globLib:City",null,"Required if any values entered for AgencyAddress","AN",null,0,35,"Field","To be completed by Agency.","City is required: To be completed by Agency."]
["3-09","County:","Agency County","No",0,1,"County","Global","globLib:County",null,null,"AN",null,0,30,"Field","To be completed by Agency."]
["3-10","State:","Agency State","No",0,1,"State","Global","globLib:State",null,"Conditionally required if Country is US then active.  If Country is not US, then inactive","LIST","50 US States, US possessions, territories, military codes",0,55,"Popup","To be completed by Agency.","State is required if Country is the United States: To be completed by Agency."]
["3-11","Province:","Agency Province","No",0,1,"Province","Global","globLib:Province",null,"If Country is US then inactive.  If Country is not US, then active","AN",null,0,30,"Field","To be completed by Agency."]
["3-12","Country:","Agency Country","No",0,1,"Country","Global","globLib:Country",null,"Required if any values entered for AgencyAddress","LIST","GENC Standard Ed3.0 Update 11",0,49,"Popup","To be completed by Agency.","Country is required: To be completed by Agency."]
["3-13","Zip / Postal Code:","Agency Zip / Postal Code","No",0,1,"ZipCode","Global","globLib:ZipPostalCode",null,"Conditionally required if Country is US then required. If Country is not US, then optional.","AN",null,0,30,"Field","To be completed by Agency.","Zip / Postal Code is required if Country is the United States: To be completed by Agency."]
["3-14","Contact Person Name:","Agency Contact Person Name Header","No",0,1,"ContactPersonName","Global","globLib:HumanNameDataType",{"$nulls":6},"Label"]
["3-15","Prefix:","Agency Prefix","No",0,1,"Prefix","Global","globLib:PrefixName",null,null,"LIST","Mr.; Mrs.; Miss; Ms.; Dr.; Rev.; Prof.",0,10,"Combobox","To be completed by Agency."]
["3-16","First Name:","Agency First Name","No",0,1,"FirstName","Global","globLib:FirstName",null,"Required if any values entered for ContactPersonName","AN",null,0,35,"Field","To be completed by Agency.","First Name is required: To be completed by Agency."]
["3-17","Middle Name:\n","Agency Middle Name","No",0,1,"MiddleName","Global","globLib:MiddleName",null,null,"AN",null,0,25,"Field","To be completed by Agency."]
["3-18","Last Name:\n","Agency Last Name","No",0,1,"LastName","Global","globLib:LastName",null,"Required if any values entered for ContactPersonName","AN",null,0,60,"Field","To be completed by Agency.","Last Name is required: To be completed by Agency."]
["3-19","Suffix:","Agency Suffix","No",0,1,"Suffix","Global","globLib:SuffixName",null,null,"LIST","Jr.; Sr.; M.D.; Ph.D",0,10,"Combobox","To be completed by Agency."]
["3-20","Telephone Number:\n","Agency Telephone Number","No","0","1","PhoneNumber","Global","globLib:TelephoneNumberDataType",null,null,"AN",null,"0",25,"Field","To be completed by Agency."]
["3-21","Additional Information:","Additional Information","No","0","1","AddedInfo","Agency-specific",null,null,null,"AN",null,"0",500,"Field","To be completed by Agency."]
["4-00","PAYEE/COMPANY INFORMATION","Payee/Company Information Header",{"$nulls":12},"Label"]
["4-01","Organization Name (Legal Name):","Organization Name","Yes",1,1,"OrganizationName","Global","globLib:OrganizationNameDataType",null,null,"AN",null,1,60,"Field","Enter the legal name of the applicant that will undertake the assistance activity. This field is required.","Organization Name is required: Enter the legal name of the applicant that will undertake the assistance activity."]
["4-02","SSN No. or Taxpayer ID No.:","SSN Number or Taxpayer ID Number","Yes","1","1","SSNTIN","Global","globLib:EmployerIDDataType",null,null,"AN",null,9,30,"Field","Enter either SSN or TIN as assigned by the Internal Revenue Service.  If your organization is not in the US, enter 44-4444444. This field is required.","SSN/TIN is required: Enter either SSN or TIN as assigned by the Internal Revenue Service.  If your organization is not in the US, enter 44-4444444.","Invalid SSN/TIN: Enter either SSN or TIN as assigned by the Internal Revenue Service.  If your organization is not in the US, enter 44-4444444."]
["4-02-1","Address:\n","Payee/Company Address Header ","Yes",1,1,"PayeeAddress","Global","globLib:AddressDataType",{"$nulls":6},"Label"]
["4-03","Street1:","Payee/Company Street1","Yes",1,1,"Street1","Global","globLib:Street1",null,null,"AN",null,1,55,"Field","Enter the first line of the Street Address. This field is required.","Street1 is required: Enter first line of the Street Address."]
["4-04","Street2:","Payee/Company Street2","No",0,1,"Street2","Global","globLib:Street2",null,null,"AN",null,0,55,"Field","Enter the second line of the Street Address."]
["4-05","City:","Payee/Company City","Yes",1,1,"City","Global","globLib:City",null,null,"AN",null,1,35,"Field","Enter the City. This field is required.","City is required: Enter the City."]
["4-06","County:","Payee/Company County","No",0,1,"County","Global","globLib:County",null,null,"AN",null,0,30,"Field","Enter the County."]
["4-07","State:","Payee/Company State","No",0,1,"State","Global","globLib:State",null,"Conditionally required if Country is US then active.  If Country is not US, then inactive","LIST","50 US States, US possessions, territories, military codes",0,55,"Popup","Select the state, US possession or military code from the provided list.  This field is required if Country is the United States.","State is required if Country is the United States: Select the state, US possession or military code from the provided list."]
["4-08","Province:","Payee/Company Province","No",0,1,"Province","Global","globLib:Province",null,"If Country is US then inactive.  If Country is not US, then active","AN",null,0,30,"Field","Enter the Province.  "]
["4-09","Country:","Payee/Company Country","Yes",1,1,"Country","Global","globLib:Country",null,null,"LIST","GENC Standard Ed3.0 Update 11",1,49,"Popup","Select the Country from the provided list.  This field is required.","Country is required: Select the Country from the provided list.  "]
["4-10","Zip / Postal Code:","Payee/Company Zip / Postal Code","No",0,1,"ZipCode","Global","globLib:ZipPostalCode",null,"Conditionally required if Country is US then required. If Country is not US, then optional.","AN",null,0,30,"Field","Enter the Postal Code (e.g., ZIP code).  This field is required if Country is the United States. ","Zip / Postal Code is required if Country is the United States. Enter the Postal Code (e.g., ZIP code)."]
["4-11","Contact Person Name:","Payee/Company Contact Person Name Header","Yes",1,1,"ContactName","Global","globLib:HumanNameDataType",{"$nulls":6},"Label"]
["4-12","Prefix:","Payee/Company Prefix","No",0,1,"Prefix","Global","globLib:PrefixName",null,null,"LIST","Mr.; Mrs.; Miss; Ms.; Dr.; Rev.; Prof.",0,10,"Combobox","Select the Prefix from the provided list or enter a new Prefix not provided on the list."]
["4-13","First Name:","Payee/Company First Name","Yes",1,1,"FirstName","Global","globLib:FirstName",null,null,"AN",null,1,35,"Field","Enter the First Name. This field is required.","First Name is required: Enter the First Name. "]
["4-14","Middle Name:","Payee/Company Middle Name","No",0,1,"MiddleName","Global","globLib:MiddleName",null,null,"AN",null,0,25,"Field","Enter the Middle Name."]
["4-15","Last Name:","Payee/Company Last Name","Yes",1,1,"LastName","Global","globLib:LastName",null,null,"AN",null,1,60,"Field","Enter the Last Name. This field is required.","Last Name is required: Enter the Last Name. "]
["4-16","Suffix:","Payee/Company Suffix","No",0,1,"Suffix","Global","globLib:SuffixName",null,null,"LIST","Jr.; Sr.; M.D.; Ph.D",0,10,"Combobox","Select the Suffix from the provided list or enter a new Suffix not provided on the list."]
["4-17","Telephone Number:","Payee/Company Telephone Number","Yes","1","1","PhoneNumber","Global","globLib:TelephoneNumberDataType",null,null,"AN",null,"1",25,"Field","Enter the daytime Telephone Number. This field is required.","Telephone Number is required: Enter the daytime Telephone Number."]
["5-00","FINANCIAL INSTITUTION INFORMATION","Financial Institution Information Header","No",{"$nulls":11},"Label"]
["5-01","Name of Financial Institution:","Institution Name ","Yes",1,1,"BankName","Agency-specific",null,null,null,"AN",null,1,55,"Field","Enter name of financial institution.  This field is required.","Institution Name is required: Enter name of financial institution. "]
["5-01-1","Address:\n","Financial Institution Address Header","Yes",1,1,"BankAddress","Global","globLib:AddressDataType",{"$nulls":6},"Label"]
["5-02","Street1:","Financial Institution Street1","Yes",1,1,"Street1","Global","globLib:Street1",null,null,"AN",null,1,55,"Field","Enter the first line of the Street Address. This field is required.","Street1 is required: Enter first line of the Street Address."]
["5-03","Street2:","Financial Institution Street2","No",0,1,"Street2","Global","globLib:Street2",null,null,"AN",null,0,55,"Field","Enter the second line of the Street Address."]
["5-04","City:","Financial Institution City","Yes",1,1,"City","Global","globLib:City",null,null,"AN",null,1,35,"Field","Enter the City. This field is required.","City is required: Enter the City."]
["5-05","County:","Financial Institution County","No",0,1,"County","Global","globLib:County",null,null,"AN",null,0,30,"Field","Enter the County."]
["5-06","State:","Financial Institution State","No",0,1,"State","Global","globLib:State",null,"Conditionally required if Country is US then active.  If Country is not US, then inactive","LIST","50 US States, US possessions, territories, military codes",0,55,"Popup","Select the state, US possession or military code from the provided list.  This field is required if Country is the United States.","State is required if Country is the United States: Select the state, US possession or military code from the provided list."]
["5-07","Province:","Financial Institution Province","No",0,1,"Province","Global","globLib:Province",null,"If Country is US then inactive.  If Country is not US, then active","AN",null,0,30,"Field","Enter the Province.  "]
["5-08","Country:","Financial Institution Country","Yes",1,1,"Country","Global","globLib:Country",null,null,"LIST","GENC Standard Ed3.0 Update 11",1,49,"Popup","Select the Country from the provided list.  This field is required.","Country is required: Select the Country from the provided list.  "]
["5-09","Zip / Postal Code:","Financial Institution Zip / Postal Code","No",0,1,"ZipCode","Global","globLib:ZipPostalCode",null,"Conditionally required if Country is US then required. If Country is not US, then optional.","AN",null,0,30,"Field","Enter the Postal Code (e.g., ZIP code).  This field is required if Country is the United States. ","Zip / Postal Code is required if Country is the United States. Enter the Postal Code (e.g., ZIP code)."]
["5-10","ACH Coordinator Name:","ACH Coordinator Name Header","Yes",1,1,"ACHCoordinator","Global","globLib:HumanNameDataType",{"$nulls":6},"Label"]
["5-11","Prefix:","ACH Coordinator Prefix","No",0,1,"Prefix","Global","globLib:PrefixName",null,null,"LIST","Mr.; Mrs.; Miss; Ms.; Dr.; Rev.; Prof.",0,10,"Combobox","Select the Prefix from the provided list or enter a new Prefix not provided on the list."]
["5-12","First Name:","ACH Coordinator First Name","Yes",1,1,"FirstName","Global","globLib:FirstName",null,null,"AN",null,1,35,"Field","Enter the First Name. This field is required.","First Name is required: Enter the First Name. "]
["5-13","Middle Name:","ACH Coordinator Middle Name","No",0,1,"MiddleName","Global","globLib:MiddleName",null,null,"AN",null,0,25,"Field","Enter the Middle Name."]
["5-14","Last Name:","ACH Coordinator Last Name","Yes",1,1,"LastName","Global","globLib:LastName",null,null,"AN",null,1,60,"Field","Enter the Last Name. This field is required.","Last Name is required: Enter the Last Name. "]
["5-15","Suffix:","ACH Coordinator Suffix","No",0,1,"Suffix","Global","globLib:SuffixName",null,null,"LIST","Jr.; Sr.; M.D.; Ph.D",0,10,"Combobox","Select the Suffix from the provided list or enter a new Suffix not provided on the list."]
["5-16","Telephone Number:","ACH Coordinator Telephone Number","Yes","1","1","PhoneNumber","Global","globLib:TelephoneNumberDataType",null,null,"AN",null,"1",25,"Field","Enter the daytime Telephone Number. This field is required.","Telephone Number is required: Enter the daytime Telephone Number."]
["5-17","Nine-Digit Routing Transit Number: ","Nine-Digit Routing Transit Number ","Yes",1,1,"NineDigitRoutingTransitNumber ","Agency-specific",null,null,"Numeric digits only","AN",null,9,9,"Field","Enter Nine-Digit Routing Transit Number. Numbers only. This field is required.","Nine-Digit Routing Transit Number is required: Enter Nine-Digit Routing Transit Number. Numbers only.","Invalid Nine-Digit Routing Transit Number: Enter Nine-Digit Routing Transit Number. Numbers only. "]
["5-18","Depositor Account Title:","Depositor Account Title","Yes","1","1","DepositorAccountTitle","Agency-specific",null,null,null,"AN",null,"1",50,"Field","Enter Depositor Account Title. This field is required.","Depositor Account Title is required: Enter Depositor Account Title."]
["5-19","Depositor Account Number:","Depositor Account Number","Yes",1,1,"DepositorAccountNumber","Agency-specific",null,null,"Numeric digits only","AN",null,4,30,"Field","Enter Depositor Account Number. This field is required.","Depositor Account Number is required: Enter Depositor Account Number.","Invalid Depositor Account Number: Enter Depositor Account Number."]
["5-20","Lockbox Number:","Lockbox Number","No",0,1,"LockboxNumber","Agency-specific",null,null,null,"AN",null,0,20,"Field","Enter Lockbox Number."]
["5-21","Type of Account:","Type of Account","No",0,1,"TypeofAccount","Radio Group",null,"Type of Account",null,"LIST",null,null,null,"Radio Group","Select Type of Account."]
["5-21-1","Checking","Checking ","No","0","1",null,"Radio Group",null,"Type of Account",{"$nulls":5},"Radio","Click to select option."]
["5-21-2","Savings","Savings","No","0","1",null,"Radio Group",null,"Type of Account",{"$nulls":5},"Radio","Click to select option."]
["5-21-3","Lockbox","Lockbox","No","0","1",null,"Radio Group",null,"Type of Account",{"$nulls":5},"Radio","Click to select option."]
["5-22","Signature and Title of Authorized Official:","Signature and Title of Authorized Official Header","Yes",1,1,"AOSignatureAndTitle","Global","globLib:HumanNameDataType",{"$nulls":6},"Label"]
["5-23","Prefix:","Authorized Official Prefix","No",0,1,"Prefix","Global","globLib:PrefixName",null,null,"LIST","Mr.; Mrs.; Miss; Ms.; Dr.; Rev.; Prof.",0,10,"Combobox","Select the Prefix from the provided list or enter a new Prefix not provided on the list."]
["5-24","First Name:","Authorized Official First Name","Yes",1,1,"FirstName","Global","globLib:FirstName",null,null,"AN",null,1,35,"Field","Enter the First Name. This field is required.","First Name is required: Enter the First Name. "]
["5-25","Middle Name:","Authorized Official Middle Name","No",0,1,"MiddleName","Global","globLib:MiddleName",null,null,"AN",null,0,25,"Field","Enter the Middle Name."]
["5-26","Last Name:","Authorized Official Last Name","Yes",1,1,"LastName","Global","globLib:LastName",null,null,"AN",null,1,60,"Field","Enter the Last Name. This field is required.","Last Name is required: Enter the Last Name. "]
["5-27","Suffix:","Authorized Official Suffix","No",0,1,"Suffix","Global","globLib:SuffixName",null,null,"LIST","Jr.; Sr.; M.D.; Ph.D",0,10,"Combobox","Select the Suffix from the provided list or enter a new Suffix not provided on the list."]
["5-28","Title of Authorized Official:","Title of Authorized Official","Yes","1","1","AOTitle","Agency-specific",null,null,null,"AN",null,"1",60,"Field","Enter title of authorized official. This field is required.","Title of Authorized Official is required: Enter title of authorized official. "]
["5-29","Telephone Number:","Authorized Official Telephone Number","Yes","1","1","AOPhoneNumber","Global","globLib:TelephoneNumberDataType",null,null,"AN",null,"1",25,"Field","Enter the daytime Telephone Number. This field is required.","Telephone Number is required: Enter the daytime Telephone Number."]