Fill and Sign the B374 Form

DEPARTMENT OF HEALTH & HUMAN SERVICES Program Support Center Division of Payment Management 5600 Fishers Lane, Room 11-33 Rockville, Maryland 20852 Division of Payment Management Financial Contact Form A Division of Payment Management financial contact is a person that accesses the Payment Management System for drawing funds, financial reporting and account inquiries. This form should be completed for the person that needs access to the Payment Management System. Please complete one form per person. Please print or type Action Requested (check one):  Establish New User Access  Change Existing User Access: Current PMS Username_____________________________________  Deactivate User Access: Current PMS Username_________________________________________ Name of Institution/Organization: ____________________________________________________ Payee Identification Number(s) (PIN): ___________________________________________________ Do you need access to all accounts associated with this PIN(s)?  Yes  No If not, please list the Payee Account Number(s) (PAN) for which you are requesting access. _________________________________________________________________________________ DUNS Number (U.S. Fish and Wildlife Service Only)________________________________________ Name of Financial Contact: ____________________________________________________________ Title of Financial Contact: ____________________________________________________________ Telephone #: ________________________________________________________________________ E-Mail Address: ______________________________________________________________________ Mailing Address: _____________________________________________________________________ ____________________________________________________________________________________ Type of access requested for user. Please select one in each category if applicable. Payment Requests and Inquiries Federal Financial Report (FFR)  Payment Requests and Inquiries  FFR Preparer Only  Inquiry Only  FFR Certifier Only  FFR Preparer and Certifier Supervisor Name (Please Print): ________________________________________________________ Supervisor’s Signature: ______________________________________________________ Supervisor’s Title: ______________________________________________________ PLEASE MAIL THIS FORM ALONG WITH YOUR SF-1199A DIRECT DEPOSIT FORM, IF BANKING INFORMATION HAS NOT BEEN ESTABLISHED IN THE PAYMENT MANAGEMENT SYSTEM FOR YOUR ACCOUNT(S). IF YOUR BANKING INFORMATION HAS BEEN ESTABLISHED, YOU MAY FAX THIS FORM TO THE PAYMENT MANAGEMENT SYSTEM HELPDESK AT 301-443-8362.