PTO-2233 Electronic Deposit Account Replenishment Form

DA Access

Page 1

PTO-2233 (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

Maintain or Replenish a USPTO Deposit Account
The Privacy Act of 1974 - as it relates to Deposit Accounts

Deposit Account Number:
Access Code:
Continue

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 replenish and maintain 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 Replenishment 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 DEPOSITS OR
COMPLETED FORMS TO THIS ADDRESS. Please refer to the Deposit Account Replenishment Options for additional instructions for replenishing
deposit accounts.

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Additional screens for Deposit Account Replenishments

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.