Form NRC Form 629 NRC Form 629 Authorization for Payment by Credit Card.

NRC FORM 629

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

APPROVED BY OMB: NO. 3150-0190

EXPIRES: (MM/DD/YYYY)

Estimated burden per response to comply with this voluntary collection request: 10 minutes. Requested
information will allow respondents to transfer funds electronically. Send comments regarding burden
estimate to the FOIA, Privacy, and Information Collections Branch (T-5 F53), U.S. Nuclear Regulatory
Commission, Washington, DC 20555-0001, or by 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.

AUTHORIZATION FOR PAYMENT
BY CREDIT CARD

“The NRC is currently accepting credit card payment of fees and other debts. The maximum amount accepted
on a credit card per invoice is $24,999.99. Splitting of a payment on multiple credit cards is not allowed. If you
wish to pay by credit card, complete the authorization below or at www.Pay.gov. If you have any questions,
please contact the NRC's Fees Resource Help Desk at (301) 415-7554.”
Company Name of Licensee

Date of Authorization

Name of Cardholder

Account Number

Cards Accepted (Check card you are using)

Address

Telephone Number

Card Expiration Date

License or Docket Number

Total Amount of Transaction

VISA

MASTERCARD

NOVUS (DISCOVER)

AMERICAN EXPRESS

*Note: Security Code is required
only if payment is submitted
through www.Pay.gov

E-mail Address

*Security Code (3 Digits)

Signature of Cardholder

Purpose of Payment:
Invoice (Number Required):
General License (Number Required):
New Application
Import/Export License
Reciprocity
Information Access Authorization Program (IAAP)
Other (NRC Reference Number or Description) (Specify below):

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

NRC FORM 629 (MM-YYYY)

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NRC FORM 629

U.S. NUCLEAR REGULATORY COMMISSION

(MM-YYYY)

AUTHORIZATION FOR PAYMENT
BY CREDIT CARD (Continued)
PRIVACY ACT STATEMENT
NRC FORM 629
AUTHORIZATION FOR PAYMENT BY CREDIT CARD
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 81 Federal Register 81342-81344 (November 17, 2016),
or the most recent Federal Register publication of the NRC's "Republication of Systems of Records
Notices" that is available 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; 31 U.S.C. Chapter 37;
31 U.S.C. 6501-6508; 42 U.S.C. 2201; 42 U.S.C. 5841; 31 CFR 900-904; 10 CFR Parts 15, 16, 170, 171;
Executive Order (E.O.) 9397, as amended by E.O. 13478; 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): Information contained in this system may be disclosed 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 Automated Clearinghouse (ACH) Network to collect a payment or debt when
the individual has given his or her authorization for this purpose. Information may be disclosed in
accordance with any of the Routine Uses listed in the Prefatory Statement of General Routine Uses,
including to an appropriate Federal, State, local or Foreign 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 Federal, State, local and Foreign 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: Controller, Division of the Controller, Office of the Chief
Financial Officer, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.

NRC FORM 629 (MM-YYYY)