Form FDA 3914 Form FDA 3914 User Fee Payment Transfer Request

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Food and Drug Administration

Form Approved: OMB No. xxxx-xxxx
Expiration Date: Xxxxxxx xx, 201x

User Fee Payment Transfer Request

See PRA Statement on page 3.

Section A: Payment Information
1. Date of Request (mm/dd/yyyy)
2. Payment Amount

3. Payment Reference Number

4. Transfer Funds From

5. Transfer Funds To

Designer note: Entry fields will
be added and the form PDF
will be made “508 compliant”
after FDA and OMB gives final
approval to this layout design.

6. Transfer Amount
7. Transfer Reason (Please explain)

Section B: Contact Information
8. Organization Name
9. Organization Address
Address 1 (Street address. No P.O. Boxes allowed)

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Address 2 (Apartment, suite, unit, building, floor, etc.)
City

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State/Province/Region

Country

ZIP or Postal Code

10. Contact Name

11. Contact Title/Position

12. Contact Phone Number (Include area code)

13. Contact Email Address

14. ACKNOWLEDGEMENT: By signing this document I acknowledge that I am the official listed on this form, authorized to
execute this request on behalf of my organization. Any questions regarding this request can be directed to me via the
contact information provided.
15. Signature

Date of Signature (mm/dd/yyyy)

Section C: FDA Acknowledgement
16. FDA Received Date (mm/dd/yyyy)

17. Center Decision
Approved

Denied

18. If Denied, State Reason
19. Decision Date (mm/dd/yyyy)

20. Center Contact Name
(FDA Acknowledgement continued, next page)

FORM FDA 3914 (5/15)

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PSC Publishing Services (301) 443-6740

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Section C: FDA Acknowledgement (Continued)
OFM Use Only
21. Request Executed?
Yes

22. If No, State Reason

No

23. Final Action

24. Date of Final Action (mm/dd/yyyy)
Completed – Transferred

Completed – Not Transferred

25. OFM Contact Name

Instructions for Completing User Fee Payment Transfer Request – Form FDA 3914
Note: Per normal procedure, on final functional form version the multi-line links will have background coding that will access the entire link shown, not just the first line of it.

Form FDA 3914 is to be completed online at http://
www.fda.gov/forindustry/userfees/default.htm and is
to be used when requesting the transfer of user fee
payments received by the FDA. If you need assistance
in completing the form contact the User Fee Helpdesk
via phone at (301) 796-7200 or email userfees@fda.
gov.

Address 1 – Enter organization’s physical street
address. No P.O. Boxes are allowed.

Section A: Payment Information

Country – Enter country where organization is
located.

Address 2 – As needed, enter apartment, suite,
unit, building, floor, etc.
City – Enter the city where organization is located.
State/Province/Region – Enter the state, province
or region where organization is located.

1. Date of Request: Enter calendar date the form is
being completed.

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2. Payment Amount: Enter the amount (in U.S.
Dollars) of the payment that is to be transferred.

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3. Payment Reference Number: If payment was
remitted via check, money order or bank draft,
enter the check or money order number; if made
electronically via Automated Clearing House (ACH)
or credit card, enter the confirmation number; if
made via wire transfer, enter the trace or Input
Message Accountability Data (IMAD) number.
4. Transfer Funds From: Enter the Payment
Identification Number (PIN) or invoice number
where payment is coming from.

ZIP or Postal Code – Enter zip code or postal
code of the organization’s location.

10. Contact Name: Enter the name of the person
requesting the transfer.
11. Contact Title/Position: Enter the position/title of
the person requesting the transfer.
12. Contact Phone Number: Enter the phone number
of the person requesting the transfer.
13. Contact Email Address: Enter the email address
of the person requesting the transfer.
14. Acknowledgement: Review acknowledgment,
confirming that you are the authorized
representative listed on this form and have
provided valid contact information in the event that
there are questions pertaining to the request.

5. Transfer Funds To: Enter the PIN or invoice
number where payment is to be applied.
6. Transfer Amount: Enter the amount (in U.S.
Dollars) that is to be transferred.

15. Signature: Place signature of listed authorizing
official here.

7. Transfer Reason: Provide a brief description of
why funds are being transferred.

Date of Signature – Date document is signed by
authorizing official.

Section B: Contact Information
8. Organization Name: This is name of the
organization listed on the cover sheet or invoice.
Entry should match both old and new cover sheets
or invoices as listed in items 4 and 5.
9. Organization Address: Enter the following
elements of the organization address.

FORM FDA 3914 (5/15)

Section C: FDA Acknowledgement
This section is for FDA use only. An FDA
representative will fill out the following items:
16. FDA Received Date: Enter date that request was
received by FDA.

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Instructions (Continued)

17. Center Decision: Check appropriate box,
indicating if request was approved or denied.

22. If No, State Reason: If response to field 21 was
“No”, provide reason.

18. If Denied, State Reason: If response to field 17
was “Denied”, provide reason.

23. Final Action: Check the appropriate box, indicating
if request was transferred or not transferred.

19. Decision Date: Enter date decision was made.

24. Date of Final Action: Enter date that final action
was taken on request.

20. Center Contact Name: Enter name of the Center’s
action officer.
21. Request Executed: Check the appropriate box,
indicating if request was executed.

25. OFM Contact Name: Enter name of the OFM
action officer.

This section applies only to requirements of the Paperwork Reduction Act of 1995.
*DO NOT SEND YOUR COMPLETED FORM TO THE PRA STAFF EMAIL ADDRESS BELOW.*
The burden time for this collection of information is estimated to average 0.25 hours per response, including the
time to review instructions, search existing data sources, gather and maintain the data needed and complete
and review the collection of information. Send comments regarding this burden estimate or any other aspect
of this information collection, including suggestions for reducing this burden, to:
Department of Health and Human Services
Food and Drug Administration
Office of Chief Information Officer
Paperwork Reduction Act (PRA) Staff
[email protected]

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“An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB number.”

PR

FORM FDA 3914 (5/15)

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