Application to Open STB Billing Account

Approved by OMB
2140-0006
Expires 1-31-2012

To be completed by STB
Account Number

SURFACE TRANSPORTATION BOARD
WASHINGTON, DC 20423-0001

APPLICATION TO OPEN AN ACCOUNT FOR BILLING PURPOSES

Name of Company

Business Address

(Street - NOTE: Post Office Box is NOT acceptable)

City, State, Zip Code

Billing Address
(If different from Business Address)

City, State, Zip Code

Telephone Number
(Include area code)
Federal Employer
Identification Number
(FEIN)

(If FEIN is not available, you may furnish the Name and Social Security Number of the Individual requesting account.)

Name of Company Financial
Officer, Treasurer, CFO, or
Billing Manager
(Name and Title)

Telephone Number (include area code)

CERTIFICATIONS:

Name (type or print)

Title

I certify that to the best of my knowledge the company does not have a delinquent Government account. I also certify that I have received, reviewed, and
understand the Account and Debt Collection Policy of the Surface Transportation Board (policy is printed on the back of this form). I further certify that
the above information is accurate to the best of my knowledge, and I fully understand that any false statements may result in prosecution under 18 U.S.C.
§ 1001, which is punishable by a fine of $10,000, five (5) years' imprisonment, or both.

Signature

Date

STB-1032 (1/12)

SURFACE TRANSPORTATION BOARD
WASHINGTON, DC 20423-0001
ACCOUNT AND DEBT COLLECTION POLICY
The Board's billing account procedures are contained in 49 CFR 1002.2(a)(2). The Board's debt collection regulations are found in 49 CFR Part 1018.
Interest, penalties, and administrative collection charges will be assessed on all overdue payments, in accordance with OMB Circular No. A-129 and
31 U.S.C. 3701, 3711-3720, except as otherwise provided in the Federal Claims Collection Standards (31 CFR 900), which are set forth in 49 CFR Part
1018.
INTEREST. Interest will be assessed on the principle of the outstanding delinquency debt. The date of delinquency is 30 days after the initial billing
date. For delinquent debts, interest and the rate of prescribed interest shall be established and accrue from the date on which notice of the debt and the
interest requirements are first mailed to the debtor or the date of delinquency, whichever is later. The minimum annual rate of interest will be calculated
by the Department of the Treasury as an average of the current value of funds to the Treasury, as published in a Treasury Bulletin. The current rate can
be obtained from the Chief, Section of Financial Services. Debts will incur interest at the annual rate in effect at the time the outstanding debt becomes
delinquent. (See 49 CFR 1018.30.)
PENALTY CHARGE. A penalty charge is a punitive charge assessed on all delinquent debts which are more than 90 days' delinquent, although the charge
will accrue on the principle and be assessed from the date of delinquency. The penalty charge set forth in the 31 U.S.C. 3717 is 6 percent per year (simple
interest). (See 49 CFR 1018.30.)
ADMINISTRATIVE COLLECTION FEE. Administrative costs incurred in the processing and handling of a delinquent debt will accrue and be accessed
from the date of delinquency. This charge will be a flat charge of $10.00 per delinquency and represents the actual cost incurred. Administrative collection fees
will be assessed every time a debt becomes more than 60 days' delinquent. (See 49 CFR 1018.30.)
ADDITIONAL COLLECTION COSTS. Any additional costs, including the cost of reporting delinquent debtors to credit bureaus, referral of debts to
commercial collection agencies, and any processing fees associated with the referral of the outstanding delinquency to the Department of the Treasury,
Debt Management Services, for offset against individual or corporate income tax refunds, or litigation by the Department of Justice, will be the
responsibility of the debtor. (See 49 CFR 1018.30.)

INSTRUCTIONS
All blanks MUST be filled in.
Each certification MUST be attested to by signature and date.
The information MUST be typed or clearly written in ink.
Those individuals who do not have a Federal Employer Identification Number may furnish their Social Security Number as authorized by Executive
Order No. 9397. Furnishing your Social Security Number is voluntary, but failure to do so will result in the denial of your request or closing of your
current account.
Your signature certifies that you have reviewed and understand the Board's account and debt collection policy.
Section 7701 of Title 31 to the U.S. Code authorizes collection of this information for agency use. In accordance with the Privacy Act, 5 U.S.C.
552a, all taxpayer identification and social security numbers are secured and used only for credit management and debt collection activities.
Disclosure of this information may be made to a collection agency, credit bureau, the Department of the Treasury, or the Department of Justice
should litigation be necessary. The information collected will not be made available to the general public.
It is estimated that an average of .08 burden hour per response is required to complete this collection of information. This estimate includes time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the
collection of information. Comments concerning the accuracy of this burden estimate or suggestions for reducing this burden should be directed to
both the Surface Transportation Board, ATTN: PRA Officer, Suite 1260, 395 E Street, SW, Washington D.C. 20423-0001, and to the Office of
Management and Budget, Office of Information and Regulatory Affairs, (OMB No.2140-0006), Washington D.C. 20503.
Submit ORIGINAL of this completed form to:
Fees and Billing
Surface Transportation Board
395 E Street, SW, Suite 1160
Washington D.C. 20423-0001