Form NRC Form 628 NRC Form 628 Financial EDI Authorization

NRC FORM 628

U.S. NUCLEAR REGULATORY COMMISSION APPROVED BY OMB: NO. 3150-0190

(mm-yyyy)

EXPIRES: mm/dd/yyyy

Estimated burden per response to comply with this voluntary collection request: 5 minutes.
Requested information will allow respondents to transfer funds electronically. Send comments
regarding burden estimate to the Records and FOIA/PrivacyServices Branch (T-5 F53), U.S.
Nuclear Regulatory Commission, Washington, DC 20555-0001, or by internet e-mail to
[email protected], and to the Desk Officer, Office of Information and Regulatory Affairs,
NEOB-10202, (3150-0190), Office of Management and Budget, Washington, DC 20503. If a
means used to impose an information collection does not display a currently valid OMB control
number, the NRC may not conduct or sponsor, and a person is not required to respond to, the
information collection.

FINANCIAL EDI AUTHORIZATION

"AGENCY"

"COMPANY"

U.S. Nuclear Regulatory Commission

provides services to

Company agrees to make payments for fees by electronic funds transfer (EFT) through the ACH Network. Agency agrees to grant
such flexibility.
Therefore, Agency hereby:
1. authorizes Company to make fee payments by EFT,
2. certifies that it has selected the following depositary financial institution, and
3. directs that all such electronic funds transfers be made as provided below:
NAME OF INSTITUTION

ACCOUNT NAME

U.S. Bank

Nuclear Regulatory Commission

ADDRESS OF DEPOSITARY INSTITUTION (include ZIP Code)

ROUTING TRANSIT NUMBER

P. O. Box 979051
Government Lock Box (SL-MO-C2GL)
St. Louis, MO 63197-9000
Can you receive an electronic
YES
invoice in the EDI 810 format?

ACCOUNT NUMBER

xxxxxxxxxx
FAX TELEPHONE NUMBER

xxxxxxxxx
NO

COMPANY NAME

Payment Format:

999-999-9999
CTX

CCD+

COMPANY ADDRESS (include ZIP Code)

COMPANY EFT CONTACT

TELEPHONE NUMBER

COMPANY TELEPHONE CONTACT

TELEPHONE

Agency shall give thirty (30) days advance, written notice to Company of any changes in depositary financial institution or other
payment instructions. When properly executed, this authorization will become effective fifteen (15) days after its receipt by Agency's
financial institution.
AUTHORIZED SIGNATURE

TITLE

DATE

PRIVACY ACT STATEMENT
Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 93-579), the following statement is furnished
to individuals who supply information to the U.S. Nuclear Regulatory Commission (NRC) on NRC Form 628. This information is maintained in a
system of records designated as NRC-32 and described at 71 Federal Register 59636 (October 10, 2006), or the most recent Federal Register
publication of the NRC's "Republication of Systems of Records Notices" that is available in the NRC's Agencywide Documents Access and
Management System (ADAMS).
1. AUTHORITY: 5 U.S.C. 552a(b)(12); 5 U.S.C. 5514; 15 U.S.C. 1681; 26 U.S.C. 6103(m)(2); 31 U.S.C. 37, subchapters I and II; 31 U.S.C.
3701(a)(3); 31 U.S.C. 3711; 31 U.S.C. 3716; 31 U.S.C. 3717; 31 U.S.C. 3718; 31 U.S.C. 3720; 42 U.S.C. 2201; 42 U.S.C. 5841; Cash
Management Improvement Act Amendments of 1992 (Pub. L. 102-589); Debt Collection Improvement Act of 1996 (Pub. L. 104-134); 31 CFR
Chapter IX, Parts 900-904; 10 CFR Parts 15, 16, 170, 171; Executive Order 9397; Executive Order 11222, as amended by Executive Orders
11590, 12107, 12565.
2. PRINCIPAL PURPOSE(S): To provide information necessary for the NRC to accept fee payments by electronic funds transfer.
3. ROUTINE USE(S): Information contained in this system may be disclosed to debt collection contractors or to other Federal agencies for the
purpose of collecting and reporting on delinquent debts and to banks enrolled in the Automated Clearinghouse (ACH) Network to collect a
payment or debt when the individual has given his or her authorization for this purpose. Information may be disclosed in accordance with any of
the Routine Uses listed in the Prefatory Statement of General Routine Uses, including to an appropriate Federal, State, local or Foreign agency in
the event the information indicates a violation or potential violation of law and in the course of an administrative or judicial proceeding. In addition,
this information may be transferred to an appropriate Federal, State, local and Foreign agency to the extent relevant and necessary for an NRC
decision about you or to the extent relevant and necessary for that agency's decision about you. Information may also be disclosed, in the course
of discovery under a protective order issued by a court of competent jurisdiction, and in presenting evidence, to a Congressional office to respond
to their inquiry made at your request, or to NRC-paid experts, consultants, and others under contract with the NRC, on a need-to-know basis.
4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION:
Providing this information is voluntary. However, not providing the requested information will not provide the NRC the information and
authorization required to accept payment of fees by electronic funds transfer.
5. SYSTEM MANAGER(S) AND ADDRESS: Director, Division of Financial Management, Office of the Chief Financial Officer, U.S. Nuclear
Regulatory Commission, Washington, DC 20555-0001.
NRC FORM 628 (mm-yyyy)

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