ST-471 Credit Card Payment Request Form

REPRODUCE LOCALLY. Include form number and date on all reproductions. Form Approved - OMB No. 0581-0055

USDA, Agricultural Marketing Service

Science and Technology Program

Plant Variety Protection Office

10301 Baltimore Avenue

Room 401, NAL Building

Beltsville, Maryland, USA 20705

(301) 504-5518

Burden and Nondiscrimination Statements

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0581-0055. The time required to complete this information collection is estimated to average .0200 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance program (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD).

To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

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 Credit Card Payment Form (ST 471). 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 PVPO to charge the appropriate fee amount to the appropriate credit card account. If you do not furnish the requested information, the PVPO 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.

Instructions for completing the Credit Card Payment Request Form

• PVPO does not accept debit cards or check cards that require use of a personal identification number as a method of payment.

• Enter all credit card information including the payment amount to be charged to your credit card and remember to sign the form. The Plant Variety Protection Office (PVPO) cannot process credit card payments without an authorized signature.

• Please list each service separately. Payment must be received in the PVP Office prior to performance of the service. Send your request directly to a secure fax line at 301-504-5796 or call the office at 301-504-5518. Ask to speak to the collections representative. You have the option to phone, fax, or mail your CREDIT CARD information (Visa, Master Card, Discover, and American Express).

• For copies, please list the number of pages and whether each page is to be authenticated. **You can get the page count per certificate from http://www.ars-grin.gov/cgi-bin/npgs/html/pvplist.pl.

• In order to process a credit card transaction we require that you provide us with the 3-digit code found on the back of the card. For security reasons, please include this information by either calling the office at 301-504-5518 or by sending it via email to [email protected].

• For a full explanation of fees, see the Regulations and Rules of Practice under the Plant Variety Protection Act, especially Section 97.175.

Fee Schedule - The listed fees are from the fee schedule in effect on October 17, 2005.

Service Cost Unit

Filing appeal to the Secretary $4,942.00 Per application/certificate

Filing a protest to the Commissioner $4,118.00 Per application/certificate

New application filing plus examination fees $4,382.00 Per application

Certificate issuance fees $768.00 Per application

Submission of new data after recommendation to issue $432.00 Per application

but before issuance

Revival of abandoned application $518.00 Per application

Correcting or re-issuance of a certificate $518.00 Per certificate

Additional fee for reconsideration $518.00 Per application

Granting of extension $89.00 Per application/certificate

Recordation fee $41.00 Per application/certificate

Copies of color photographs $41.00 Per application/certificate

Late fee $41.00 Per application/certificate

Seed replenishment fee $38.00 Per application/certificate

Copies $1.80 Per page of material

Additional fee for authentication of copies $1.80 Per page of material

Field inspection or other services requiring travel Actual costs

Other services, including training classes $107.00 Per hour, and per examiner

Request for Services			Plant Variety Protection Office USDA, AMS, S&T NAL Building, Room 401 10301 Baltimore Blvd. Beltsville, MD 20705 Phone 301-504-5518 Fax 301-504-5796 E-mail: [email protected]
DATE: _____________________________________ (Month/Day/Year (ie. 03/15/2005))
CREDIT CARD INFORMATION (BY PHONE, FAX OR PAPER MAIL): Cardholder's Name: _________________________________________ (Please Type or Print Name as it appears on the Card) Card type: ___________________ Expiration Date: _____________ Account Number: _______________________ 3-digit code __ __ __ Billing Address ________________________________________ Address Line 2 _________________________________________ City, State, Zip Code ____________________________________ County________________________________________________ Phone ________________________________________________ Fax __________________________________________________ E-Mail ________________________________________________ Cardholder's Signature:________________________________					Requested on behalf of: (Skip If same as Cardholder) Name ________________________________________________ Company Name ________________________________________ Street Address _________________________________________ City, State, Zip Code ____________________________________ Country _______________________________________________ Phone ________________________________________________ Fax __________________________________________________ E-Mail ________________________________________________
Service Requested	PV Number	Crop Kind/Species		Variety Name/Designation			Copies (# of Pages) **See GRiN Database	Unit Price	TOTAL
For Plant Variety Protection Office Use Only: Date Paid: __________________________ Agency Tracking ID: ___________________________ Amount Paid: ___________________________ PVP Personnel: ___________________________ Confirmation No: ___________________________								TOTAL	$

ST-471 (02-06) designed by the Plant Variety Protection Office Page 2 of 3