Form ST-471 Credit Card Payment Request for Services 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
1400 Independence Avenue, SW
Room 4512-South Building, Mail Stop 0274
Washington, DC 20250-0002
(202) 260-8983
Burden Statement
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 .5
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.
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
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PVPO does accept debit cards or check cards that require use of a personal identification number as a method of
payment.
Enter all credit/debit 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 202-260-8976 or call the office at 202-260-8983. 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).
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 202-260-8983 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.

ST-471 Revised (10/2015) designed by the Plant Variety Protection Office

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REPRODUCE LOCALLY. Include form number and date on all reproductions.

Form Approved - OMB No. 0581-0055

Fee Schedule - The listed fees are from the fee schedule in effect on October 17, 2005.
Service
1. Filing appeal to the Secretary

Cost
$4,942.00

Unit
Per application/certificate

2.

Filing a protest to the Commissioner

$4,118.00

Per application/certificate

3.

New application filing plus examination fees

$4,382.00

Per application

4.

Certificate issuance fees

$768.00

Per application

5.

Submission of new data after recommendation to issue

$432.00

Per application

but before issuance
6.

Revival of abandoned application

$518.00

Per application

7.

Correcting or re-issuance of a certificate

$518.00

Per certificate

8.

Additional fee for reconsideration

$518.00

Per application

9.

Granting of extension

$89.00

Per application/certificate

10. Recordation fee

$41.00

Per application/certificate

11. Copies of color photographs

$41.00

Per application/certificate

12. Late fee

$41.00

Per application/certificate

13. Seed replenishment fee

$38.00

Per application/certificate

14. Copies

$1.80

Per page of material

15. Additional fee for authentication of copies

$1.80

Per page of material

16. Field inspection or other services requiring travel

Actual costs

17. Other services, including training classes

$107.00

ST-471 Revised (10/2015) designed by the Plant Variety Protection Office

Per hour, and per examiner

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REPRODUCE LOCALLY. Include form number and date on all reproductions.

Form Approved - OMB No. 0581-0055

Plant Variety Protection Office
USDA, AMS, S&T
1400 Independence Avenue, SW
Room 4512-South Building, Mail Stop 0274
Washington, DC 20250-0002
Phone 202-260-8983 Fax 202-260-8976
E-mail: [email protected]

Request for Services

Date:_________________________
(Month/Day/Year (ie. 03/15/2005))

Credit Card and/or ACH Debit Information (By Phone, Fax, or Paper Mail):
Account Holder’s Name:___________________________________________
(Please Type or Print Name as it appears on Account)
Credit Card Type: _________________Expiration Date ____________________
(Visa, Master Card, Discover, and American Express)
Account Number:_____________________________ 3-Digit Code:__________

Requested on Behalf of: (skip if same as Account Holder)
Name: ______________________________________________________
Company Name: ____________________________________________
Street Address:________________________________________________
City, State, Zip Code: ___________________________________________

Billing Address:____________________________________________________

Country: _____________________________________________________

Address Line 2:____________________________________________________

Phone: ______________________ Fax:____________________________

City, State, Zip Code: _______________________________________________

Email: _______________________________________________________

Email:___________________________________________________________
Account Holder’s Signature:_________________________________________
(ACH Debit Card) Money Transfer
Account Type: ____________________________________________________
Routing Number ( 9 digits): _________________________________________
Account Number: ________________________________________________
Email:___________________________________________________________
Account Holder’s Signature:_________________________________________
Service Requested

PV Number

Crop Kind/Species

Variety name/Designation

Copies (# of Pages)
$1.80/page

Unit
Price

Total:

For Plant Variety Protection Office Use Only:
Date Paid: ______________________________________
Agency Tracking ID: ______________________________
Amount Paid: ___________________________________
Confirmation No: ________________________________
PVP Personnel: __________________________________

ST-471 Revised (10/2015) designed by the Plant Variety Protection Office

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Total

REPRODUCE LOCALLY. Include form number and date on all reproductions.

Form Approved - OMB No. 0581-0055

USDA’s Nondiscrimination Statement
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights
regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or
administering USDA programs are prohibited from discriminating based on race, color, national origin,
religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status,
family/parental status, income derived from a public assistance program, political beliefs, or reprisal or
retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all
bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.
Persons with disabilities who require alternative means of communication for program information (e.g.,
Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or
USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay
Service at (800) 877-8339. Additionally, program information may be made available in languages other than
English.
To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form,
AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or
write a letter addressed to USDA and provide in the letter all of the information requested in the form. To
request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA
by:
1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400
Independence Avenue, SW Washington, D.C. 20250-9410;
2) fax: (202) 690-7442; or
3) email: [email protected].
USDA is an equal opportunity provider, employer, and lender.

ST-471 Revised (10/2015) designed by the Plant Variety Protection Office

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