Fsa-isd-441-d One Time Credit Card Payment Authorization

United States Department of Agriculture

OMB Control No. 0560-0176

OMB Expiration Date: 12/31/2021

FPAC-ISD-441D (proposal 1)

Farm Production and Conservation-Business Center Geospatial Enterprise Operations 125 South State Street Suite 6416 Salt Lake City UT 84138-1102 (801)-844-2923 ONE TIME CREDIT CARD PAYMENT AUTHORIZATION

Sign and complete this form to authorize the Geospatial Enterprise Operations (GEO) to make a one-time debit to your credit card listed below. By signing this form, you give us permission to debit your account for the amount indicated on or after the indicated date. This is permission for a single transaction only and does not provide authorization for any additional unrelated debits or credits to your account.

Please complete the information below:

I,

     

authorize Geospatial Enterprise Operations (GEO) to charge

my credit card account indicated below for $

     

on or after

     

.

(amount)

(date)

This payment is for

     

.

Billing Address:

     

Phone Number:

     

City, State, Zip:

     

Email:

     

Customer Code:

     

Work Order Number:

     

Account Type: Visa MasterCard AMEX Discover

Cardholder Name:

     

Account Number :

     

Expiration Date:

     

CVC Number:

     

SIGNATURE

DATE      

I authorize the above-named business to charge the credit card indicated in this authorization form according to the terms outlined above. This payment authorization is for the goods/services described above, for the amount indicated above only, and is valid for one time use only. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

NOTE:

The following statement is made in accordance with the Privacy Act of 1974 (5 USC 552a - as amended).  The authority for requesting the information identified on this form is the Agricultural Adjustment Act of 1938 (7 U.S.C. 1387).  The information will be used to process an order for aerial photography.  The information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for USDA/FSA-2, Farm Records File (Automated).  Providing the requested information is voluntary.  However, failure to furnish the requested information will result in an inability on the part of the Aerial Photography Field Office to process the order for aerial photography. Public Burden Statement (Paperwork Reduction Act): 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 0560-0176. The time required to complete this information collection is estimated to average 30 minutes 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. The provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided.  RETURN THIS COMPLETED FORM TO THE USDA FPAC-BC GEOSPATIAL ENTERPIRSE OPERATIONS AT THE ADDRESS LISTED ON PAGE 1.

FPAC-ISD-441D (proposal 1) Page 2

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.