Form 5510 PDF Details

Understanding the significance of the Standard Form 5510, or more commonly known as the Authorization Agreement for Preauthorized Payments, is crucial for those seeking to facilitate smooth transactions with the Department of the Treasury. This form plays a pivotal role in authorizing electronic fund transfers directly from an individual or company's account, ensuring a streamlined process for the collection of payments. Mandated under various statutes including the Electronic Fund Transfer Act (15 USC § 1693 et seq.), alongside regulations set forth in 12 CFR 205 and 31 CFR 206 and 210, the form is designed to safeguard the interests of both the paying and receiving parties. By meticulously aligning the records of the government agency with those of the financial institutions, it guarantees accuracy in the direction of payments. The provision to start, change, or stop automatic debit entries provides flexibility and control to the account holder, while adherence to U.S. law in the origination of ACH transactions is underscored. Obtaining this signed authorization is a statutory requirement without which electronic fund transfers cannot proceed, highlighting the form's indispensability in government-related financial transactions. Given the blend of voluntary participation and potential consequences of non-compliance, which may include delays or inability to process payments electronically, the careful completion of this form, recognized under OMB Control Number 1530-0015, becomes imperative.

QuestionAnswer
Form NameForm 5510
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmedicare gov form 5510, irs form 5510, sf 5510 form, medicare form sf 5510 pdf

Form Preview Example

AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS

OMB Control Number: 1530-0015

Expiration Date: 6/30/2020

(AGENCY NAME)

Paperwork Reduction Act/Privacy Act Statement

The information requested on this form is required under the Electronic Fund Transfer Act (15 USC § 1693 et seq.), 12 CFR 205, and 31 CFR 206 and 210, for the purpose of authorizing the Department of the Treasury to electronically collect payments from your account. The information will be used to match the records of the government agency with those of the financial institution to direct your payments to the point you authorize. No pre-authorized electronic fund transfer from your account may be transacted unless a signed authorization form is received. Furnishing this information is voluntary; however, failure to furnish this information may delay or prevent the electronic collection of a payment through the Automated Clearing House. You are not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this collection of information is 1530-0015. We estimate that it will take approximately 15 minutes to complete this form.

CHECK ONE

START

CHANGE

STOP

INDIVIDUAL/COMPANY INFORMATION

INDIVIDUAL/ORGANIZATION NAME (PLEASE PRINT)

STREET ADDRESS

CITY/STATE

ZIP CODE

AREA CODE

TELEPHONE NUMBER

YOUR AGENCY ACCOUNT IDENTIFICATION NUMBER

TYPE OF PAYMENT

I hereby authorize the initiation of the debit entries from my account listed below and the financial institution named below to debit such account. I understand I will be notified if the debit amount needs to be adjusted, either to be increased or decreased. I also understand that I have the right to stop automatic payment by notifying my financial institution in writing three days prior to the time my account is to be charged. I/we acknowledge that the origination of ACH transactions to my/our account must comply with U.S. law. This authorization is to remain in full force and effect until the agency listed above has received written notification from me in such time and in such manner as to afford the agency listed above and the financial institution listed below a reasonable opportunity to act upon it.

SIGNATURE

 

DATE

 

 

 

 

FINANCIAL INSTITUTION INFORMATION

FINANCIAL INSTITUTION NAME

STREET ADDRESS

CITY/STATE

ZIP CODE

NINE-DIGIT ROUTING TRANSIT NUMBER

ACCOUNT TITLE

ACCOUNT NUMBER

CHECKING

SAVINGS

SIGNATURE AND TITLE OF REPRESENTATIVE

AREA CODE/TELEPHONE NUMBER

DATE

DEPARTMENT OF THE TREASURY

PREVIOUS EDITION NOT USABLE

STANDARD FORM 5510 (REV. 3/2017)

AUTHORIZED FOR LOCAL REPRODUCTION

 

Prescribed by 12 CFR 205; 31 CFR 206 and 210; I TFM 6-8000

 

 

How to Edit Form 5510 Online for Free

The filling out the medicare form 5510 is really straightforward. We ensured our PDF editor is not hard to work with and helps complete almost any PDF in no time. Take a look at several steps you'll want to take:

Step 1: First, press the orange button "Get Form Now".

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Fill out the medicare form 5510 PDF by providing the text required for each individual section.

filling in form sf 5510 step 1

Inside the field YOUR AGENCY ACCOUNT IDENTIFICATION, TYPE OF PAYMENT, I hereby authorize the initiation, SIGNATURE, DATE, FINANCIAL INSTITUTION INFORMATION, FINANCIAL INSTITUTION NAME, STREET ADDRESS, CITYSTATE, NINEDIGIT ROUTING TRANSIT NUMBER, ACCOUNT TITLE, and ZIP CODE provide the details the system requires you to do.

form sf 5510 YOUR AGENCY ACCOUNT IDENTIFICATION, TYPE OF PAYMENT, I hereby authorize the initiation, SIGNATURE, DATE, FINANCIAL INSTITUTION INFORMATION, FINANCIAL INSTITUTION NAME, STREET ADDRESS, CITYSTATE, NINEDIGIT ROUTING TRANSIT NUMBER, ACCOUNT TITLE, and ZIP CODE blanks to insert

Type in all particulars you need within the field ACCOUNT NUMBER, CHECKING, SAVINGS, SIGNATURE AND TITLE OF, AREA CODETELEPHONE NUMBER, DATE, DEPARTMENT OF THE TREASURY, PREVIOUS EDITION NOT USABLE, and STANDARD FORM REV Prescribed by.

Filling out form sf 5510 step 3

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