DC Courts Vendor Establishment Request Form

Date:*

Requestor *

Request Type *

Budget and Finance Division Use Only
SAM Registration Waived, FAR Clause			SAM Waiver Approver
Supplier Classification:			Supplier Type
DCC Service Type			Pay Group
Payment Terms

PRIVACY ACT STATEMENT
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. 33Z 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

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. 33Z 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.

The information entered below should match your entity’s SAM registration.

Supplier Name *

(*** Supplier Name should be the exact entity name registered in SAM ***)

Unique Entity Identifier (UEI) *

(*** Unique Entity Identifier (UEI) should be the assigned 12-digit alpha and numeric code assigned by SAM to your registered entity ***)

Cage Code *

(*** SAM Registration activation code ***)

Taxpayer ID *

( *** Please enter Tax ID registered in SAM ***)

ALC (if Federal)

Trading Partner ID: (if Federal)

Mailing Address *

(*** Please enter the complete mailing address including State and ZIP ***)

Bank Name

Bank Routing Number (ABA)

Bank Account Number

Checking/Savings

Checking

Saving

Additional Information Required from Defender Services Suppliers Only

	Attorney Bar No.
	Non-attorney

DC Courts Web Voucher System (Select Program) *

CJA

CCAN

Probate

CRRD

Email Address *

Optional Information
Alternate Name
Telephone Number
Contact Info
E-mail Address

IBC Use Only The above information has been added/updated into Oracle and data input verified for accuracy according to procedures
Data input by		On date
Passed verification by		On date

IBC Use Only

The above information has been added/updated into Oracle and data input verified for accuracy according to procedures

Data input by

On date

Passed verification by

On date