APHIS 192 Application for Credit Account

Clear Form
According to the Paperwork Reduction Act of 1995, no persons are 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 0579-0055. The time required to complete this information
collection is estimated to average .25 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.

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE

OMB Approved
0579-0055
EXP. XX/XXXX

APPLICATION FOR CREDIT ACCOUNT

1. ACCOUNT TYPE (check applicable blocks)
VETERINARY SERVICES USER FEE

OTHER SERVICES (specify):

PLANT PROTECTION AND QUARANTINE
REIMBURSABLE OVERTIME

2. APPLICANT NAME AND TITLE

3. FIRM NAME (As shown in Box 1 of your attached W9)

5. BILLING ADDRESS

6. PHYSICAL LOCATION ADDRESS

7. TELEPHONE NUMBER

8. FAX NUMBER

4. DATE BUSINESS STARTED

9. EMAIL ADDRESS

10. ACCOUNT CONTACT NAME(S)

11. PRINCIPAL OFFICER(S) AND/OR OWNER(S) INFORMATION
OFFICER OR OWNER

OFFICER OR OWNER

OFFICER OR OWNER

NAME

TITLE

HOME ADDRESS

TELEPHONE NUMBER
12. LIST OTHER TRADE NAMES, SUBSIDIARIES, BRANCHES, DIVISIONS, PARENTS, ETC.

13. ORGANIZATION TYPE
INDIVIDUAL

PARTNERSHIP

14. NUMBER OF EMPLOYEES

CORPORATION

COLLEGE OR
UNIVERSITY

15. DO YOU OWN OR RENT YOUR BUILDING?
OWN
RENT

STATE
GOVERNMENT

FEDERAL
GOVERNMENT
AGENCY

OTHER (specify):

16. IF RENTING, PROVIDE LANDLORD INFORMATION
NAME:
TELEPHONE NUMBER:

17. IRS TAX IDENTIFICATION NUMBER OR APPLICANT’S SOCIAL SECURITY NUMBER (check one and provide the number. If not provided, credit will not be issued.)
TAX ID NUMBER
SOCIAL SECURITY NUMBER
18. FORMER BUSINESS LOCATION(S) FOR THE PAST SEVEN YEARS

PRIVACY ACT STATEMENT
Section 552 of Title 5 to the U.S. Code authorizes collection of this information. The primary use of this information is to gather data that will be used to establish a credit
account for the purchase of goods and services from the Animal and Plant Health Inspection Service. User fees are authorized by Section 2509(c)(1) of the Food, Agriculture,
Conservation and Trade Act of 1990, amended by the Omnibus Budget Reconciliation Act of 1990, referred to as the 1990 Farm Bill, (21 U.S.C. 136 and 136a and 21 U.S.C.
135). Information collected will be used by Federal employees who have a need for the information in the performance of their official duties. Additional disclosures of this
information may be made to Federal, State, local, or foreign agencies in relation to investigations of civil, criminal, or regulatory investigations or prosecutions, to the court of
competent jurisdiction, to the United States Department of Agriculture's office of Inspector General's Office in connection with user fees reviews, and to consumer reporting
agencies in accordance with Section 3711 (f) of Title 31.
Your social security account number is solicited under the authority of the Internal Revenue Code (26 U.S.C. 6011 (b) and 6109) and Executive Order 9397, November 22,
1943, for use as a taxpayer and/or employee identification number. Disclosure of your social security number and other requested information is voluntary; however, failure to
provide the information may result in disapproval of your request for credit.

APHIS FORM 192
SEP 2020

Previous editions are obsolete.

19. CURRENT BANK ACCOUNT INFORMATION
CHECKING ACCOUNT

SAVINGS ACCOUNT

NAME OF FINANCIAL
INSTITUTION

ADDRESS

TELEPHONE NUMBER

FAX NUMBER

YEARS ACCOUNT OPEN
20. BUSINESS OR PROFESSIONAL CREDIT REFERENCES (list 3)
REFERENCE 1

REFERENCE 2

REFERENCE 3

NAME

ADDRESS

TELEPHONE NUMBER

FAX NUMBER
21. APHIS LOCATIONS TO BE NOTIFIED OF THE ACCOUNT NUMBER

AGREEMENTS
This information contained in this application is for the purpose of obtaining credit and is warranted to be true. I/We hereby authorize the agency to whom this application is
made to investigate the information given herein pertaining to my/our credit and financial responsibilities. I/We have used services 6 times, plan on continuing to use services
6 times per year, and do not already have an account under this Federal Tax ID Number.
It is hereby agreed that the USDA APHIS will be reimbursed by the applicant upon completion of services. Payment will be made at the rate(s) established for services in
accordance with 7 CFR Part 354 and 9 CFR Parts 97 and 130.
If the account becomes past due it will be placed in a cash on delivery (COD) basis requiring payment at the time of service.
A current IRS Form W-9 is attached to the completed application; I/we acknowledge an incomplete application may delay establishing an account.
Applicants’ signatures attest understanding, financial responsibility, authority, ability and willingness to pay all debts, interest, penalties, and administrative costs.
22. SIGNATURE NAME(S) AND TITLE(S)

23. AUTHORIZED SIGNATURE(S) (seals)

24. DATE

25. REMARKS

To protect the sensitive information in this application,
it is recommended this form and attachments be emailed to [email protected].
Otherwise, use accountable mail or a similar service to send the packet to
USDA APHIS FMD FOB, Attn: APHIS ARS Team, 250 Marquette Ave, Suite 410, Minneapolis, MN 55401.
For customer service inquiries, please call (877) 777-2128.
FOR OFFICIAL USE ONLY
26. ACCOUNT NUMBERS ASSIGNED

APHIS FORM 192 (REVERSE)

27. APPROVING ANALYST

28. DATE