Form 3881-A: ACH Vendor/Miscellaneous Payment Enrollment - HCTC

Form 3881-A is an enrollment form for Automated Clearing House (ACH) payments, also called Electronic Funds Transfers (EFTs), for HCTC. The form says it is used for ACH payments with an addendum record that contains payment-related information processed through the Direct Deposit Program.

It is completed by the payee or Health Plan Administrator (HPA) that will manage the ACH vendor or miscellaneous payments, together with the financial institution that will receive them. The form says recipients of these payments should bring it to their financial institution when presenting it for completion. It is not a form an individual taxpayer files with a return.

The instructions are on page 2 of the PDF. You can fill out the form free in your browser on this page and download it without an account.

What's on Form 3881-A

1. Agency Information

Federal program agency, agency identifier, Agency Location Code (ALC), address, contact person, telephone and fax numbers, and the ACH format: CCD+ or CTX.

2. Payee/Company Information

Boxes for New or Annual renewal, then name, SSN or taxpayer ID number, address, contact name, email and telephone number.

Health Plan Provider

An optional line for a health plan provider, if any, with its telephone number.

3. Financial Institution Information

Bank name, optional address and contact, nine-digit routing transit number, depositor account number and account type: checking, savings or general ledger.

Signature of authorized official

Signature, title and telephone number of the authorized official, followed by the Privacy Act Statement and Paperwork Reduction Act Notice.

How to fill out Form 3881-A

1
New or renewal
Check New or Annual renewal at the top of section 2.
2
Payee details
Print or type the payee/HPA name and address, the SSN or taxpayer ID number (the instructions say it may also be called the employer identification number), and the contact person, email and phone.
3
Health Plan Provider
If needed, enter the name of any third party health care company the HPA uses, with its telephone number.
4
Bank details
Enter the financial institution's name, the nine-digit routing transit number, the depositor account number and the account type. Address and contact are optional on the form.
5
Verify the account
The instructions say the payee verifies the depositor account number and type of account entered by the financial institution.
6
Signature
The bank official signs with title and phone number. If the payee contact completed section 3, the instructions say no bank official signature is required.

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How it is used and what to know

Take it to the bank

The form says recipients of these payments should bring this information to the attention of their financial institution when presenting the form for completion.

No mailing address printed

The form and its page 2 instructions print no address to send the completed form to.

Why the information is collected

The Privacy Act Statement says it is required under 31 U.S.C. 3322 and 31 CFR 210, and that missing information may delay or prevent the receipt of payments through the Automated Clearing House Payment System.

Time to complete

The form says the estimated average time to complete it is 15 minutes.

Who completes Form 3881-A?

Payee or Health Plan Administrator
The instructions say section 2 holds the name and address of the payee/HPA that will manage the ACH payments, its SSN or taxpayer ID number and a contact person.
Financial institution
Section 3 holds the bank that will receive the ACH payment, the routing and account numbers, and the signature, title and phone number of the bank official.
Payee contact who knows the bank details
The instructions say the payee/company contact may complete the financial institution section if they know all the bank information, and that no bank official signature is required.
Third party health care company
If the HPA uses a third party health care company, its name goes on the Health Plan Provider line with a telephone number.
Federal program agency
Section 1 holds the agency originating the payment: its name, address, identifiers, contact and ACH format.

The form is filled in by the payee or Health Plan Administrator and its financial institution, to set up ACH payments from the federal program agency named in section 1.

Official sources and the blank

Official IRS form page
The agency’s own page for Form 3881-A.
Official instructions
How the IRS says to fill out and file Form 3881-A.
Blank PDF
The official blank form, to print or fill by hand.

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Questions about Form 3881-A

What is Form 3881-A for?

The form says it is used for ACH payments with an addendum record that contains payment-related information processed through the Direct Deposit Program, for HCTC.

Who fills out Form 3881-A?

The payee or Health Plan Administrator completes section 2, and the financial institution completes section 3. The payee contact may complete section 3 if they know all the bank information.

Does a bank official have to sign?

The form has a line for an authorized bank official, but the instructions say there is no requirement for a bank official signature when the payee contact completes the bank section.

What does New or Annual renewal mean?

Section 2 has two boxes, New and Annual renewal, to show whether the enrollment is new or a yearly renewal.

Where are the instructions for Form 3881-A?

They are printed on page 2 of the same PDF, section by section.

Form 3881-A: ACH Vendor/Miscellaneous Payment Enrollment - HCTC