PTO-2231 Electronic Credit Card Payment Form

PTO Secure Payment Server Payment Form

https://ramps.uspto.gov/eram/Controller;jsessionid=ramps.uspto.gov...

Privacy Act and Paperwork Reduction Act - as it relates to Credit Cards.
Item Purchase Description:
DEPOSIT ACCOUNT REPLENISHMENT
Amount:
$1.00

Please verify that the above information is correct and then complete the payment
form. Fields labeled in bold text are required.

Select the credit card type for this transaction:
Visa
Mastercard
American Express
Discover
Enter the credit card number:
Enter the credit card expiration date:
Month Sep (09)
Year 2003
Enter the name as it appears on the credit card:
Enter your billing address:
Street Address 1:
Street Address 2:
City:
State:

CLICK TO SELECT

Zip or Postal:
Country:

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9/12/03 10:55 AM

United States Patent & Trademark Office

https://ramps.uspto.gov/eram/privacyActCreditCard.html

United States Patent & Trademark Office
Electronic Credit Card Payment Form
Paperwork Reduction Act Statement
Approved for use through 02/28/2006 under OMB Control Number 0651-0043. This collection of information is
required by 15 U.S.C. § 1113 or 35 U.S.C. § 41 and 37 CFR 1.16-1.28, 1.492, or 2.6-2.7. The information must
be provided by a member of the public if he or she chooses to pay a U.S. Patent and Trademark Office fee by
credit card. This information is also used by the U.S. Patent and Trademark Office to charge the appropriate fee
amount to the appropriate credit card account. This collection is estimated to take two minutes to complete,
including gathering information, preparing and submitting the Electronic Credit Card Payment Form to the U.S.
Patent and Trademark Office. Time will vary depending upon the individual case. Any comments on the amount
of time you require to complete this form and/or suggestions for reducing this burden should be sent to the
Chief Information Officer, U.S. Patent and Trademark Office, Washington, DC 20231. DO NOT SEND FEES
OR COMPLETED FORMS TO THIS ADDRESS.
Privacy Act Advisory Statement
The Privacy Act of 1974 (P.L. 93-579) requires that you be given certain information in connection with the
request for information solicited on the Electronic Credit Card Payment Form. Accordingly, pursuant to the
requirements of the Act, please be advised that: (1) the authority for the collection of this information is 15
U.S.C. § 1113 or 35 U.S.C. § 41 and 37 CFR 1.16-1.28, 1.492, or 2.6-2.7; (2) furnishing of the information
solicited is voluntary; and (3) the principal purpose for which the information is used by the U.S. Patent and
Trademark Office is to charge the appropriate fee amount to the appropriate credit card account. If you do not
furnish the requested information, the U.S. Patent and Trademark Office may not be able to charge the fee to
the credit card or the credit card institution may refuse to accept the charge, either of which will result in the fee
being treated as not having been paid.
The information provided by you in this form will be subject to the following routine uses:
(1) The information on this form will be treated confidentially to the extent allowed under the Freedom of
Information Act (5 U.S.C. § 552) and the Privacy Act (5 U.S.C. § 552(a)). Records from this system of records
may be disclosed to the Department of Justice to determine whether disclosure of these records is required by
the Freedom of Information Act.
(2) A record from this system of records may be disclosed, as a routine use, in the course of presenting
evidence to a court, magistrate or administrative tribunal, including disclosures to opposing counsel in the
course of settlement negotiations.
(3) A record in this system of records may be disclosed, as a routine use, to a Member of Congress submitting
a request involving an individual when the individual has requested assistance from the Member with respect to
the subject matter of the record.
(4) A record in this system of records may be disclosed, as a routine use, to a contractor of the Agency having
need for the information in order to perform the contract. Recipients of information shall be required to comply
with the requirements of the Privacy Act of 1974, as amended, pursuant to 5 U.S.C. § 552a(m).
(5) A record from this system of records may be disclosed, as a routine use, to the Administrator, General
Services, or his designee, during an inspection of records conducted by GSA as part of that agency's
responsibility to recommend improvements in records management practices and programs, under authority of
44 U.S.C. § 2904 and § 2906. Such disclosure shall be made in accordance with the GSA regulations
governing inspection of records for this purpose, and any other relevant (i.e., GSA or Commerce) directive.
Such disclosure shall not be used to make determinations about individuals.

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