Note: To be completed by an Individual payee for payments such as honorariums and travel reimbursement or Brown University students for prize payments. We require the same name/SSN combination as it appears on your income tax return. Section 1: Payee's General Information First Namerequired First name of Individual Payee. Last Namerequired Last name of Individual Payee. Emailrequired Email address of Individual Payee. Phone Numberrequired Telephone number of the Individual Payee. Individual Payee's Permanent Address Address Line 1required Number & Street or PO Box. Address Line 2 Cityrequired State (select N/A if non-US address)required Please Select N/AAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip or Postal Code (indicate N/A if none)required Countryrequired Individual Payee's Mailing Address Address Line 1required Number & Street or PO Box. Address Line 2 Cityrequired State (select N/A if non-US address)required Please Select N/AAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip or Postal Code (indicate N/A if none)required Countryrequired Please provide one of the following U.S. tax numbersrequired Social Security Number Individual Tax ID Number (ITIN) No U.S. tax reporting number Social Security Number Individual Tax ID Number Provide the International Tax ID number Are you a Foreign National/Resident of another country?required Yes No If you are a US Permanent Resident card holder please select No. If yes, what country issued the recipient's passport? Brown Department Informationrequired Name of Brown University Department contact. Reason for Payment to Individualrequired Section 2: Bank Account Information EFT (Direct Deposit) payments are available for U.S. Banks Only. This form authorizes Brown University to make payments to an individual electronically and to deposit funds into the account specified below. It also authorizes Brown University and the bank to initiate the transaction(s) necessary to correct an error. This electronic payment authorization will remain in effect until the University has received written notification from the payee to terminate and the University has had reasonable opportunity to act upon it. Notification of payments will be sent by email, with the payment settling into your bank account within two days. It is the responsibility of the individual to notify Brown of any changes pertinent to electronic payments, such as changes in banking information or email address. Select account type: Checking Savings Name of Bank Name on Bank Account Bank Routing Number (9 digits) Account Number How to Find the Routing Number on Your Check Funds Transfer: To comply with the requirements of the U.S. Department of Treasury and Office of Foreign Assets Control (OFAC), Brown is obligated to ask the question shown below regarding the transferring funds. If your answer is “Yes”, Brown will issue a paper check in lieu of processing a direct deposit. Are funds transferred to the designated direct deposit account and then transferred to a bank in a foreign country? Yes No denotes required fields.Required
