NRC Form 629 Authorization for Payment by Credit Card

NRC FORM 629

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

(mm-yyyy)

AUTHORIZATION FOR PAYMENT
BY CREDIT CARD

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/Privacy Services 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.

The NRC is currently accepting credit card payment of fees and other debts. If you wish to
pay by credit card, complete the authorization below. If you have any questions, contact
NRC's collection service provider, Department of Interior/National Business Center at
303-969-5880.
NAME OF CARDHOLDER

ACCOUNT NUMBER

ADDRESS

CARD EXPIRATION DATE

CARDS ACCEPTED (Check card you are using)

TELEPHONE

LICENSE NUMBER

INVOICE NUMBER OR DESCRIPTION

TOTAL AMOUNT OF TRANSACTION

VISA

MASTERCARD

DINERS
CLUB

AMERICAN
EXPRESS

NOVUS
(DISCOVER)
USA CARD

SIGNATURE OF CARDHOLDER

If you are paying an application or registration fee (including new licenses, amendments,
etc.), mail the completed form with your application to the appropriate regional office.
For all other payments, send completed form to:
U.S. Bank
U.S. Nuclear Regulatory Commission
Accounts Receivable Team
P. O. Box 979051
St. Louis, MO 63197-9000
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 629. 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 located in the NRC's Agencywide Documents Access and
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 (E.O.) 9397; E.O. 11222, as amended by E.O.s 11590, 12107,
2. PRINCIPAL PURPOSE(S): To collect credit card account information and provide authorization for its use to collect a payment or debt.
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 Treasury Credit Card Network to collect a payment or debt
when the individual has given his or her credit card number for this purpose. Information may be disclosed in accordance with any of the routine
uses listed in the Prefatory Statement of General Routine Uses which includes to an appropriate agency in the event the information indicates a
violation or potential violation of law; in the course of an administrative or judicial proceeding; to an appropriate 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; 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; to NRC-paid experts, consultants, and others under contract with the NRC, on a need-to-know basis; and to
appropriate persons and entities for purposes of response and remedial efforts in the event of a suspected or confirmed breach of data from this
system of records.
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 use your credit card to collect a payment or debt.
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 629 (mm-yyyy)

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