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US Marine Corps Personal and Family Readiness Division ACH Application Form I hereby authorize the U.S. Marine Corps Personal and Family Readiness Division Marine Corps Exchange Centralized Accounts Payable hereinafter called MCCS-MRF to initiate credit and debit entries to the account indicated below with the financial institution named below hereinafter called DEPOSITORY to credit or debit the same to such account. All information collected on this form is required under the provisions of the Federal Financial Management Act of 1994 Section 3332 of title 31 of U.S.C. This information will be used by the MCCS Financial Management Office 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 ACH Program.. CANCEL Stop my participation in the program. AXS-One Vendor ID Name as shown on invoice Not Applicable Address City State Zip Accounts Receivable AR Point of Contact POC Name Telephone Number AR POC Fax Number AR POC E-mail Address Depositor Account Number Name of Financial Institution Street Address Phone Routing Number CHECKING SAVINGS OTHER Signature Date Printed Name Title To be completed by MCCS Date Received Date Completed Completed By ACH Remit ID PRIVACY ACT STATEMENT The following information is provided to comply with the Privacy Act of 1974. All information collected on this form is required under the provisions of the Federal Financial Management Act of 1994 Section 3332 of title 31 of U.S.C. All fees and charges that may be applied by the DEPOSITORY for the receipt and processing of transfers will be my sole responsibility. This authority is to remain in full force and effect until such time as MCCS-MRF has received written notification from me of its termination/change. Written notification shall be provided to MCCS-MRF at least thirty 30 working days prior to the effective date of termination/change. Check One I am not currently participating in the MCCS-MRF ACH Program* ADD Credit/Debit my payment to the account shown* I am currently participating in the MCCS-MRF ACH Program* CHANGE Change financial institutions and/or account number. CANCEL Stop my participation in the program* AXS-One Vendor ID Name as shown on invoice Not Applicable Address City State Zip Accounts Receivable AR Point of Contact POC Name Telephone Number AR POC Fax Number AR POC E-mail Address Depositor Account Number Name of Financial Institution Street Address Phone Routing Number CHECKING SAVINGS OTHER Signature Date Printed Name Title To be completed by MCCS Date Received Date Completed Completed By ACH Remit ID PRIVACY ACT STATEMENT The following information is provided to comply with the Privacy Act of 1974. All information collected on this form is required under the provisions of the Federal Financial Management Act of 1994 Section 3332 of title 31 of U*S*C. This information will be used by the MCCS Financial Management Office 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 ACH Program*.

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