PTO-2232 Deposit Account Application Form

Finance, Office of - Deposit Account Application Form

United States Patent and Trademark Office

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Office of Finance > Receipts Accounting Division > Deposit Account Branch > Deposit Account Application Form
PTO-2232 (02-2006)
Approved for use through 02/28/2009. OMB 0651-0043
U. S. Patent and Trademark Office; U.S. DEPARTMENT OF COMMERCE
Under the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.

Please enter the information requested below, and then print the completed form on your local printer. Please see the bottom
of this form for mailing instructions.
If you require additional information about deposit accounts, the types of deposit accounts offered by the U.S. Patent and
Trademark Office, and initial payment and fees required for establishing and maintaining a deposit account, please visit the
Deposit Account Rules and Information page.
Date:
Type of Account Requested:
c Unrestricted (minimum $1,000)
d
e
f
g

c Restricted (minimum $300)
d
e
f
g
c Universal Public Work Station (UPWS) (minimum $300)
d
e
f
g
Account setup fee: $10.00
Company Name (to appear on
monthly Deposit Account Statement):
Attention:
Address:
City, State, and Zip Code:
Telephone Number:
Fax Number:
Primary Contact Email Address:
Taxpayer ID Number:
If this account is for a government
agency, please provide the Agency
Location Code (ALC) #:

Authorized Users List:

Finance, Office of - Deposit Account Application Form

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Please attach additional pages as needed
Mailing Instructions: Please mail the completed form along with your initial deposit and the fee required to establish your
deposit account ($10.00) to the address below. Please make checks payable to the Director of the United States Patent and
Trademark Office.
Mail Stop 16
Director of the US Patent and Trademark Office
PO Box 1450
Alexandria, VA 22313-1450
If you have any questions or require additional information, please contact the Deposit Account Branch at (571) 272-6500 or
send an email to [email protected].
This collection of information is required by 35 U.S.C. § 41 or 15 U.S.C. § 1113 and 37 CFR 1.21(b), 1.25, 2.6, and 2.208. The
information is required in order for the public to establish a deposit account at the USPTO. This form is estimated to take 2
minutes to complete, including gathering information, preparing, and submitting the completed Deposit Account Application
Form to the USPTO. Time will vary depending upon the individual case. Please send any comments on the amount of time
required to complete this form and/or suggestions for reducing this burden to the Chief Information Officer, USPTO, PO Box
1450, Alexandria, VA 22313-1450. DO NOT SEND FEES OR COMPLETED FORMS TO THIS ADDRESS. PLEASE REFER
TO THE MAILING INSTRUCTIONS ABOVE FOR THE CORRECT MAILING ADDRESS FOR COMPLETED FORMS.
Privacy Act Statement for Deposit Account Application Form
[Deposit Account Branch] [Maintenance Fee Branch] [Refund Branch]
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Last Modified: 04/25/2007 09:30:56

The Privacy Act of 1974 (P

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Privacy Act Statement for Deposit Accounts
The Privacy Act of 1974 (P.L. 93-579) requires that you be given certain information in connection with your request for, or
maintenance of, a deposit account. Accordingly, pursuant to the requirements of the Act, please be advised that: (1) the
authority for the collection of this information is 35 U.S.C. § 2, 37 CFR 1.25, and 37 CFR 2.208; (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 establish a deposit account, maintain existing accounts, or charge the appropriate fee amount to the
appropriate deposit account. If you do not furnish the requested information, the U.S. Patent and Trademark Office may not
be able to establish a deposit account, properly account for funds submitted to maintain the account, or debit fees from the
correct deposit account.
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.