Form PTO-2232 Deposit Account Application Form

Finance, Office of - Deposit Account Application Form

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Office of Finance > Receipts Accounting Division > Deposit Account Branch > Deposit Account Application Form

PTO-2232 (02-2006)
Approved for use through 12/31/2011. OMB 0651-0043
U. S. 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.

Please enter the information requested below, and then print the completed form on your local printer or use the
print version to print. Please see the bottom of this form for mailing instructions.
If you require additional information about deposit accounts, the types of deposit accounts offered by the U.S.
Patent and Trademark Office, and initial payment and fees required for establishing and maintaining a deposit
account, please visit the Deposit Account Rules and Information page.
Date:
Type of Account Requested:
c Unrestricted (minimum $1,010)
d
e
f
g

c Restricted (minimum $310)
d
e
f
g
(The required $10 account setup fee is included above.)
Company Name (to appear on
monthly Deposit Account Statement):
Attention:
Address:
City, State, and Zip Code:
Telephone Number:
Fax Number:
Primary Contact Email Address:
Taxpayer ID Number:
If this account is for a government
agency, please provide the Agency
Location Code (ALC) #:

Authorized Users List:

http://www.uspto.gov/web/offices/ac/comp/fin/depaccapp.htm

9/26/2011

Finance, Office of - Deposit Account Application Form

Please attach additional pages as needed
Mailing Instructions: Please mail the completed form along with your initial deposit and the fee required to
establish your deposit account (at least $1,010.00 or $310.00, depending on the type of account requested)
to the address below. Please make checks payable to the Director of the United States Patent and
Trademark Office.
Via first-class mail:
Mail Stop 16
Director of the US Patent and Trademark Office
PO Box 1450
Alexandria, VA 22313-1450
Via delivery service (e.g., FedEx, UPS, etc.):
Director of the US Patent and Trademark Office
Attn: Deposit Accounts
2051 Jamieson Avenue, Suite 300
Alexandria, VA 22314
If you have any questions or require additional information, please contact the Deposit Account Branch at
(571) 272-6500

This collection of information is required by 35 U.S.C. § 41 or 15 U.S.C. § 1113 and 37 CFR 1.21(b), 1.25, 2.6, and
2.208. The information is required in order for the public to establish a deposit account at the USPTO. This form is
estimated to take 2 minutes to complete, including gathering information, preparing, and submitting the completed
Deposit Account Application Form to the USPTO. Time will vary depending upon the individual case. Please send
any comments on the amount of time required to complete this form and/or suggestions for reducing this burden to
the Chief Information Officer, USPTO, PO Box 1450, Alexandria, VA 22313-1450. DO NOT SEND FEES OR
COMPLETED FORMS TO THIS ADDRESS. PLEASE REFER TO THE MAILING INSTRUCTIONS ABOVE FOR
THE CORRECT MAILING ADDRESS FOR COMPLETED FORMS.
Privacy Act Statement for Deposit Account Application Form
[Deposit Account Branch] [Maintenance Fee Branch] [Refund Branch]
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http://www.uspto.gov/web/offices/ac/comp/fin/depaccapp.htm

9/26/2011

The Privacy Act of 1974 (P

Privacy Act Statement for Deposit Accounts
The Privacy Act of 1974 (P.L. 93-579) requires that you be given certain information in connection with your
request for, or maintenance of, a deposit account. Accordingly, pursuant to the requirements of the Act, please be
advised that: (1) the authority for the collection of this information is 35 U.S.C. § 2, 37 CFR 1.25, and 37 CFR
2.208; (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 establish a deposit account, maintain existing
accounts, or charge the appropriate fee amount to the appropriate deposit account. If you do not furnish the
requested information, the U.S. Patent and Trademark Office may not be able to establish a deposit account,
properly account for funds submitted to maintain the account, or debit fees from the correct deposit account.
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 records management 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.

https://ramps.uspto.gov/eram/privacyActDepositAccount.html

9/26/2011