NRC Form 629 Authorization for Payment by Credit Card

NRC FORM 629

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 Information 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.

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

(M-YYYY)

AUTHORIZATION FOR PAYMENT
BY CREDIT CARD

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)
VISA

MASTERCARD

NOVUS
(DISCOVER)

AMERICAN
EXPRESS
TELEPHONE

LICENSE NUMBER

INVOICE NUMBER OR DESCRIPTION

TOTAL AMOUNT OF TRANSACTION

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 as part
of 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
Management System.
1. AUTHORITY: 5 U.S.C. 552a; 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. 12101; and E.O. 12731.
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): In addition to the disclosures permitted under subsection (b) of the Privacy Act, NRC may disclosed information 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 (M-YYYY)