Fill and Sign the Form G 1450 Authorization for Credit Card Uscis

United States Patent & Trademark Office Instructions for Completing the Credit Card Payment Form Credit Card Information § Fill in all credit card information including the payment amount to be charged to your credit card and your signature. The United States Patent and Trademark Office (USPTO) cannot process credit card payments without an authorized signature. § The USPTO does not accept debit cards or check cards that require use of a personal identification number as a method of payment. Credit Card Billing Address § Address information is required for credit card payment as a means of verification. Failure to complete the address information, including zip/postal code, may result in the payment not being accepted byyour credit card institution. Request and Payment Information § Provide a description of your request based on the payment amount. For example, indicate the item as “basic filing fee” (patent) or “first maintenance fee” (patent maintenance fee) or “application for registration” (trademark) or “certified copy of a patent” (other fee). § Indicate the nature of your request by the type of fee you wish to pay: Patent Fee, Patent Maintenance Fee, Trademark Fee or Other Fee. Complete information for each type of fee as applicable to identify the natureof your request. Indicate only one type of fee per form. § If you are requesting and paying a fee based on a previously filed patent or trademark application, indicatethe application or serial number, patent number, or registration number that is associated with your request.“Other Fee” is used to request copies of patent and trademark documents, certified copies, assignments, and other information products. § IDON numbers are assigned by the USPTO for customers ordering patent and trademark information andproducts specified as “Other Fee” on the order form. If you have been assigned an IDON number from a previous customer order, include it with your request. § For more information on USPTO fees and amounts, refer to the current fee schedule at http://www.uspto.go v . To request a copy by mail, contact the USPTO General Information Services at 800-786-9199 or 703-308-4357. Important Information § The USPTO will not include the Credit Card Payment Form among the patent or trademark records open for public inspection. Failure to use the Credit Card Payment Form when submitting a credit card payment may result in the release of your credit card information . § Information on mailing addresses is available at http://www.uspto.gov (under site index-addresses, mailing). You may also contact the USPTO for additional information or to request a copy of the Basic Facts about Patents or Basic Facts about Trademarks information booklet by calling 800-786-9199 or 703-308-4357. United States Patent & Trademark Office Instructions for Completing the Credit Card Payment Form Paperwork Reduction Act Statement Form PTO-2038. Approved for use through 01/31/2003 under OMB Control Number 0651-0043. This collection of information is required by 15 U.S.C. 1113 or 35 U.S.C. 41 and 37 CFR 1.16-1.26, 1.492, or 2.6- 2.7. The information must be provided by a member of the public if he or she chooses to pay a U.S. Patent and Trademark Office fee by credit card. This information is also used by the U.S. Patent and Trademark Office to charge the appropriate fee amount to the appropriate credit card account. This collection is estimated to take 12 minutes to complete, including gathering, preparing and submitting the Credit Card Form to the U.S. Patent andTrademark Office. Time will vary depending upon the individual case. Any comments on the amount of time you require to complete this form and/or suggestions for reducing this burden should be sent to the Chief Information Officer, U.S. Patent and Trademark Office, Washington, DC 20231. DO NOT SEND FEES ORCOMPLETED FORMS TO THIS ADDRESS. PLEASE REFER TO THE USPTO WEB SITE, UNDER"SITE INDEX-ADDRESSES, MAILING” FOR THE CORRECT MAILING ADDRESS. 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 Form PTO-2038. 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 1.16-1.26, 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 U.S. Patent and Trademark Office is to charge theappropriate fee amount to the appropriate credit card account. If you do not furnish the requested information, theU.S. Patent and Trademark Office 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. The information provided by you in this form will be subject to the following routine uses: (1)The information on this form will be treated confidentially to the extent allowed under the Freedom of Information Act (5 U.S.C. 552) and the Privacy Act (5 U.S.C. 552(a)). Records from this system of records may be disclosed to the Department of Justice to determine whether disclosure of these records is required by the Freedom of Information Act. (2) A record from this system of records may be disclosed, as a routine use, in the course of presenting evidence to a court, magistrate or administrative tribunal, including disclosures to opposing counsel in the course of settlement negotiations. (3) A record in this system of records may be disclosed, as a routine use, to a Member of Congress submitting a request involving an individual when the individual has requested assistance from the Member with respect to the subject matter of the record. (4) A record in this system of records may be disclosed, as a routine use, to a contractor of the Agency having need for the information in order to perform the contract. Recipients of information shall be required to comply with the requirements of the Privacy Act of 1974, as amended, pursuant to 5 U.S.C. 552a(m). (5) A record from this system of records may be disclosed, as a routine use, to the Administrator, General Services, or his designee, during an inspection of records conducted by GSA as part of that agency’s responsibility to recommend improvements in recordsmanagement practices and programs, under authority of 44 U.S.C. 2904 and 2906. Such disclosure shall be made in accordance with the GSA regulations governing inspection of records for this purpose, and any other relevant ( i.e., GSA or Commerce) directive. Such disclosure shall not be used to make determinations about individuals. PTO-2038 (02-2000) Approved for use through 01/31/2003. OMB 0651-0043 United States Patent and Trademark Office; U.S. DEPARTMENT OF COMMERCE Under 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. United States Patent & Trademark OfficeCredit Card Payment Form Please Read Instructions before Completing this Form Credit Card Information Credit Card Type:  Visa  MasterCard  American Express  Discover Credit Card Account #: Credit Card Expiration Date: Name as it Appears on Credit Card: Payment Amount: $(US Dollars): Signature: Date: Refund Policy: The Office may refund a fee paid by mistake or in excess of that required. A change of purpose after the payment of a fee will not entitle a party to a refund of such fee. The Office will not refund amounts of twenty-five dollars or less unless a refund is specifically requested, and will not notify the payor of such amounts (37 CFR 1.26). R efund of a fee paid by credit card will be via credit to the credit card account. Service Charge: There is a 50.00 service charge for processing each payment refused (including a check returned “unpaid”) or charged back by a financial institution (37 CFR 1.21(m)). Credit Card Billing Address Street Address 1: Street Address 2: City: State: Zip/Postal Code : Country: Daytime Phone #: Fax #: Request and Payment Information Description of Request and Payment Information:  Patent Fee  Patent Maintenance Fee  Trademark Fee  Other Fee Application No. Application No. Serial No.IDON Customer No. Patent No. Patent No. Registration No. Attorney Docket No.Identify or Describe Mark If the cardholder includes a credit card number on any form or document other than the Credit Card Payment Form, the United States Patent & Trademark Office will not be liable in the event that the credit card number becomes public knowledge.