Forms for Electronic Payments - AT&T

1 Forms for Electronic PaymentsSBC Trading Partners Business CustomersPayment System Value AddedNetworksBuilding Electronic Partnerships For The Data Interchange - Electronic Funds Transfer BY SBC All Rights ReservedTable of ContentsForms & Reference Material for Electronic PaymentsCustomer Information form for Electronic Payments .. ECF11 Customer Information form for Electronic Payments (Gov. Agencies) .. ECF11 GElectronic Funds Transfer ECF12 Trading Partner Profile for Electronic Remittance Requirements for Electronic Payments .

2 ECR52 ECF11 (Rev 07/03)Customer Information form for Electronic PaymentsElectronic Payments for: _____ SBC - AR, KS, MO, OK, TX _____ SBC - IL, IN, MI, OH, WI_____ SBC - CA, NV _____ Revised InformationSend completed form to:SBC EDI/EFT Control CenterOne Bell Center, Room 39-T-8 Telephone: 1-314-235-5422St. Louis, Missouri 63101-3099 FAX.

3 1-314-235-5476 CUSTOMER COMPANY INFORMATIONName _____ Address _____ City, State, Zip _____ Treasury Contact Daily Operations Contact Name _____ Name _____ Title _____ Title _____ Phone _____ Phone _____CUSTOMER DEPOSITORY FINANCIAL INSTITUTION (DFI) INFORMATION DFI Name _____ Address _____ City, State, ZIP _____ EDI/EFT Contact Daily Operations Contact Name _____ Name _____ Title _____ Title _____ Phone _____ Phone _____CUSTOMER (PAYOR)

4 PAYMENT IDENTIFICATION DFI RTN/ABA Number ____ ____ ____ ____ ____ ____ ____ ____ ____ (ACH Company/Batch Header field, position 80-87) Company Identification ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ (ACH Company/Batch Header field, position 41-50) Company Name ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ (ACH Company/Batch Header field, position 05-20)CUSTOMER (PAYOR) OPTIONSP ayment Option Remittance Option___ CCD___ Separate EDI 820 Transaction Set (*) - Version _____ CCD+___ EDI RMT/DTM Segment(s) in Addenda Record___ Cross-reference in Addenda Record for Separate EDI 820 Transaction Set (*)Version _____ CTX___ EDI RMT/DTM Segment(s)

5 In Addenda Record(s)___ EDI 820 Transaction Set in Addenda Records - Version _____(*) Also complete SBC Trading Partner Profile for Electronic PaymentsCompleted By _____Phone _____Date _____ECF11G (Rev 07/03)Customer Information form for Electronic PaymentsElectronic Payments for: _____ SBC - Southwestern Bell _____ SBC - Ameritech_____ SBC - Pacific Bell/Nevada Bell _____ Revised InformationSend completed form to:SBC EDI/EFT Control CenterOne Bell Center, Room 39-T-8 Telephone: 1-314-235-5422St.

6 Louis, Missouri 63101-3099 FAX: 1-314-235-5476 CUSTOMER INFORMATIOND epartment _____ Agency _____Agency Location Code (ALC) _____ Address _____ City, State, Zip _____ Treasury Contact Daily Operations Contact Name _____ Name _____ Title _____ Title _____ Phone _____ Phone _____CUSTOMER FMS or DFAS DISBURSING OFFICE Disbursing Office Name _____ Address _____ City, State.

7 ZIP _____ EDI/EFT Contact Daily Operations Contact Name _____ Name _____ Title _____ Title _____ Phone _____ Phone _____CUSTOMER (PAYOR) PAYMENT IDENTIFICATION Disbursing Office RTN/ABA Number _____ _____ _____ _____ _____ _____ _____ _____ (ACH Company/Batch Header field, position 80-87) Agency Identification _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ (ACH Company/Batch Header field, position 41-50) Agency Name ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ (ACH Company/Batch Header field, position 05-20)CUSTOMER (PAYOR) OPTIONSP ayment Option Remittance Option___ CCD+___ EDI RMT/DTM Segment(s)

8 In Addenda Record___ Cross-reference in Addenda Record for Separate EDI 820 Transaction Set (*)Version _____ CTX___ EDI RMT/DTM Segment(s) in Addenda Record(s)___ EDI 820 Transaction Set in Addenda Records - Version _____(*) Also complete SBC Trading Partner Profile for Electronic PaymentsCompleted By _____Phone _____Date _____ ECF12 (Rev 10/01) Electronic Funds Transfer Authorization_____(SBC Affiliate) sells goods and/or services to (Customer) and/orto one or more of its wholly owned desires the option to make Payments for such goods and/or services by electronicfunds transfer (EFT) through the Automated Clearing House (ACH) and SBC desirescustomer to have such , SBC hereby ( 1 ) authorizes Customer to make Payments for goods andservices by EFT, ( 2 )

9 Certifies that it has selected the following depository institution,and ( 3 ) directs that all such EFTs be made as provided below:Depository Institution: Address: Bank Routing Number: Account Name: Account Number: NACHA Payment Format.

10 SBC Services EFT Contact:Name: Phone #: The parties agree that the terms and conditions of all their agreements concerning the methodof payment for goods and services shall be amended as provided will give thirty ( 30 ) days advance notice in writing to Customer of any changes in itsdepository institution or other payment : Title.