Form G-1450 Authorization for Credit Card Transactions

Authorization for Credit Card Transactions

USCIS
Form G-1450

Department of Homeland Security
U.S. Citizenship and Immigration Services

OMB No. 1615-NEW
Expires 00/00/20xx

General Information
Complete the "Applicant's Information," "Credit Card Billing Information," and "Credit Card Information" sections and sign
the authorization. U.S. Citizenship and Immigration Services (USCIS) cannot process credit card payments without an authorized
signature. Failure to provide the requested information may result in USCIS and your financial institution not accepting the payment.

USCIS Privacy Act Statement
AUTHORITIES: The information requested on this authorization, and the associated evidence, is collected under section 286(m)
of the Immigration and Nationality Act, 8 U.S.C. 1356(m).
PURPOSE: The primary purpose for providing the requested information is to authorize the USCIS Lockbox to make an electronic
credit card payment in Pay.gov, which is owned and operated by the Department of Treasury, for the filing fee and biometric services
fee associated with a benefit request form. USCIS will process your case when the payment is received in full.
DISCLOSURE: The information you provide is voluntary. However, failure to make a payment towards the associated benefit
request filing fee and biometric services fee may delay or prevent USCIS from accepting your benefit request form.

DRAFT
NOT FOR
PRODUCTION
07/13/2015

ROUTINE USES: This information may be used by and disclosed to USCIS personnel and contractors or other agents who need the
information to assist in activities related to processing associated fees. Additionally, USCIS may disclose the information to other
Federal, state, local, and authorized organizations in accordance with approved routine uses, as described in the associated published
system of records notice [TREASURY/FMS.017 - Collections Records --Treasury/Financial Management Service, which can be found at
http://www.treasury.gov/privacy, and DHS-USCIS-007 - Benefits Information System, available at www.dhs.gov/privacy]. The
information may also be made available, as appropriate, for law enforcement purposes or in the interest of national security.

Paperwork Reduction Act

An agency may not conduct or sponsor an information collection, and a person is not required to respond to a collection of information,
unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 5
minutes per response, including the time for reviewing instructions and completing and submitting the authorization. Send comments
regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:
U.S. Citizenship and Immigration Services, Regulatory Coordination Division, Office of Policy and Strategy, 20 Massachusetts Ave,
NW, Washington, DC 20529-2140; OMB No. 1615-NEW. Do not mail your completed Form G-1450 to this address.

Applicant's Information

Applicant's Full Legal Name:
Given Name (First Name)

Middle Name (if any)

Family Name (Last Name)

Credit Card Billing Information

Credit Card Holder's Name as it appears on the card:
Given Name (First Name)

Middle Name (if any)

Family Name (Last Name)

Credit Card Holder's Billing Address:
Street Number and Name
City or Town

Apt. Ste. Flr.

Number

State

ZIP Code

Credit Card Holder's Contact Information and Signature:
Credit Card Holder's Email Address

Credit Card Holder's Daytime Telephone Number

Credit Card Holder's Signature

Credit Card Information
Credit Card Type:
Credit Card Number

Form G-1450 01/20/15

Visa

MasterCard

American Express

Discover

Credit Card Expiration Date

Authorized Payment Amount

(mm/yyyy)

$

.00
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