Privacy Act Statement Sample Clauses

Privacy Act Statement. Collection and use is covered by Privacy Act System of Records INTERIOR/DOI–05 Interior Volunteer Services File System (which may be viewed at ▇▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/privacy/doi-notices) and OPM/GOVT–1 General Personnel Records (which may be viewed at ▇▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/information-management/privacy-policy/#url=SORNs) and is consistent with the provisions of 5 USC 552a (Privacy Act of 1974), which authorizes acceptance of the information requested on this form. The information is used to identify persons interested in participating in a government volunteer program, managing the volunteer program, including tort claims and injury compensation. Records or information contained in this system may be disclosed outside the agencies participating in this program as a routine use pursuant to 5 U.S.C. 552a(b)

Privacy Act Statement. The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). All information collected on this form is required under the provisions of 31 U.S.C. 3322 and 31 CFR 210. This information will be used by the Treasury Department 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 Automated Clearing House Payment System. FEDERAL PROGRAM AGENCY AGENCY IDENTIFIER: AGENCY LOCATION CODE (ALC): ACH FORMAT: CCD+ CTX ADDRESS: CONTACT PERSON NAME: TELEPHONE NUMBER: ( ) ADDITIONAL INFORMATION: NAME SSN NO. OR TAXPAYER ID NO. ADDRESS CONTACT PERSON NAME: TELEPHONE NUMBER: ( ) NAME: ADDRESS: ACH COORDINATOR NAME: TELEPHONE NUMBER: ( ) NINE-DIGIT ROUTING TRANSIT NUMBER: DEPOSITOR ACCOUNT TITLE: DEPOSITOR ACCOUNT NUMBER: LOCKBOX NUMBER: TYPE OF ACCOUNT: CHECKING SAVINGS LOCKBOX SIGNATURE AND TITLE OF AUTHORIZED OFFICIAL: (Could be the same as ACH Coordinator) TELEPHONE NUMBER: ( ) AUTHORIZED FOR LOCAL REPRODUCTION SF 3881 (Rev. 2/2003 ) Prescribed by Department of Treasury 31 U S C 3322; 31 CFR 210 Make three copies of form after completing. Copy 1 is the Agency Copy; copy 2 is the Payee/Company Copy; and copy 3 is the Financial Institution Copy.

Privacy Act Statement. Authority ─ This information is being collected under the authority of 5 U.S.C. § 4115, a provision of The Government Employees Training Act.

Privacy Act Statement. The NIH maintains application and grant records as part of a system of records as defined by the Privacy Act: NIH 09-25-0225 ▇▇▇▇▇://▇▇▇.▇▇▇.▇▇▇/privacy-act-and-era.htm.

Privacy Act Statement. Section 6109 of the Internal Revenue Code requires you (Issuer) to provide us with your correct Taxpayer Identification Number (TIN).

Privacy Act Statement. The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). All information collected on this form is required under the provisions of 31 U.S.C. 3322 and 31 CFR 210. This information will be used by the Treasury Department 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 Automated Clearing House Payment System. FEDERAL PROGRAM AGENCY AGENCY IDENTIFIER: AGENCY LOCATION CODE (ALC): ACH FORMAT: CCD+ CTX ADDRESS: CONTACT PERSON NAME: TELEPHONE NUMBER: ( ) ADDITIONAL INFORMATION: NAME SSN NO. OR TAXPAYER ID NO. ADDRESS CONTACT PERSON NAME: TELEPHONE NUMBER: ( ) NAME:

Privacy Act Statement. The Department of Housing and Urban Development (HUD) is authorized to collect the information required on this form by Section 8 of the U.S. Housing Act of 1937 (42 U.S.C. 1437f). Collection of family members’ names and unit address, and owner’s name and payment address in mandatory. The information is used to provide Section 8 tenant-based assistance under the Housing Choice Voucher program in the form of housing assistance payments. The information also specifies what utilities and appliances are to be supplied by the owner, and what utilities and appliances are to be supplied by the tenant. HUD may disclose this information to Federal, State, and Local agencies when relevant to civil, criminal, or regulatory investigations and prosecutions. It will not be otherwise disclosed or released outside of HUD, except as permitted or required by law.

Privacy Act Statement. The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). All information collected on this form is required under the provisions of 31 U.S.C. 3322 and 31 CFR 210. This information will be used by the Treasury Department 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 Automated Clearing House Payment System.

Privacy Act Statement. 1. To the extent any of the information that VA has a right to request from Provider or that Provider is otherwise required to provide VA under the terms of this Agreement constitutes “information” within the meaning of 5 USC 552a(e), and without prejudice to any other terms of this Agreement or the rights or obligations of the Parties under those terms, the following Privacy Act Statement applies. 2. VA's authority to solicit such information is 38 USC 1703A. VA's principal intended purposes for collecting such information is to use such information to establish, determine, and monitor eligibility of non-VA health care providers to furnish health care services authorized under chapter 17 of title 38, USC, as well as all uses arising under or related to the Agreement, including the exercise of any rights and discharge of any obligations thereunder. Other uses of this information include, but are not limited to, reporting healthcare provider earnings to the Internal Revenue Service; Third Party Liability, preparing responses to inquiries; performing statistical analyses for use in managerial activities, resource allocation and planning; processing and adjudicating administrative benefit claims by VBA Regional Office (RO) staff; conducting audits, reviews and investigations by staff of the VA healthcare facility, Veterans Integrated Service Network (VISN) Offices, VAFSC, VA Headquarters, and the VA Office of Inspector General (OIG); in the conduct of law enforcement investigations; and in the performance of quality assurance audits, reviews and investigations. 3. Information will be maintained in the System of Records described in System of Record Notice, 23VA10NB3, entitled “Non-VA Care (Fee) Records-VA”, published at 80 FR 45590 (July 30, 2015). VA may disclose such information for routine uses 2, 7, and 30, described below and as otherwise noted in the referenced System of Records Notice. These records may also be disclosed as part of an ongoing computer- matching program to accomplish these purposes. (a) A record from this system of records may be disclosed to a Federal, State, or local government agency, maintaining civil, criminal, or other relevant information, such as current licenses, registration or certification, if necessary, to obtain information relevant to an agency decision concerning the hiring or retention of an employee, the use of an individual as a consultant, attending or to provide Non-VA Care (fee), the issuance of a security clearanc...