Form ST-212 Alternate Payment Form

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

Form Approved - OMB No. 0581-NEW

USDA, Agricultural Marketing Service

Science and Technology Programs
Technical and Field Laboratory Services
1400 Independence Avenue, SW
Washington, DC 20250
Burden and Nondiscrimination Statements
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-New. The time required to complete this information collection is
estimated to average .0500 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.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of
race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status,
religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income
is derived from any public assistance program (Not all prohibited bases apply to all programs.) Persons with disabilities
who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should
contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD).
To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W.,
Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity
provider and employer.
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 Alternate Payment Form (ST-212). 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 Science and Technology Programs (S&T) is to charge the appropriate fee amount
to the appropriate credit card account. If you do not furnish the requested information, S&T 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 Alternate Payment Form
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Enter all company and contact information in the space provided.
Check box for appropriate service provider (e.g. Field Laboratory Services or Technical Services Branch);
provide a brief description of the service provided: enter the Billing Document Number (TSB) or Invoice Number
(Laboratory Programs).
Enter the total payment amount to be charged to your account.
Select payment option: either credit card or ACH
For credit cards, check appropriate box and enter the name and number on the card.
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 ACH transfers, enter the 9-digit routing number found at the bottom left of the check and the account
number found at the bottom of the check to the right of the routing number.
Remember to sign the form, date it and print your name below your signature. Science and Technology
Programs cannot process credit card payments without an authorized signature.
You have the option to fax or mail your completed form to the S&T Payment Center.
Completed forms should be mailed to the S&T Payment Center, USDA, AMS, S&T, FLS/TSB, 801 Summit
Crossing Place, Suite B, Gastonia, NC 28054-2105 or Faxed to 704-853-2800.
Questions? 704-867-3873

ST-212 (12-07) designed by S&T Technical and Laboratory Services

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United States Department of Agriculture
Agricultural Marketing Service
Science and Technology Programs
Field Laboratory and Technical Services

ALTERNATE PAYMENT FORM

FAX or Mail Form to:
Attn: Payment Center
USDA, AMS, S&T, FLS/TSB
801 Summit Crossing Place, Suite B
Gastonia, NC 28054-2105
FAX 704-853-2800

To make a payment to your account using a credit card or an electronic check (Automated Clearing House (ACH) ,
Debit) please fill in this form and fax or mail to the address shown above. Required fields indicated with an asterisk.

Company Name:*
Account Number:*
Address:*
Name of Contact:*
City, State, Zip:*
Contact’s Phone:*

Contact’s Email:*

*Service Provider (check one):

Field Laboratory Services

Technical Services Branch

Description of Service:
*Payment Amount:

*Invoice or Billing Document No:

*Select Payment Option 1 or 2 by inserting an "X" into the appropriate box below
Option 1

Pay by Credit Card
Select Credit Card:

American Express
Discover

Master Card
Visa

Diners Club/Carte Blanche

Name as shown on Credit Card:
Number on Credit Card:
Expiration Date of Credit Card (mm/yy) :

3 Digit Security Code:

The security code is found on either the front or back of the credit card. It usually follows the credit card number.
For payment we will need this code. For security purposes the code can be provided to the Payment Center over the telephone.

Option 2

Pay by Electronic Check (ACH Debit)

Bank Routing Number:
Checking Account Number:
By signing this application, I authorize the United States Department of Agriculture, Agricultural Marketing Service,
Science and Technology Programs to use the above information for the purpose of collecting payment for services provided.

*
Cardholder Signature

Questions? 704-867-3873

Date

*
Print Name

For Office Use Only
Agency Tracking ID

Processing Clerk's Name

Pay.Gov Tracking ID
ST-212-(12-07) designed by S&T Technical and Laboratory Services

Date Transaction Completed