ST-473 Recordation Form

REPRODUCE LOCALLY. Include form number and date on all reproductions. Form Approved OMB NO 0581-0055

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 0581-0055. The time required to complete this information collection is estimated to average .5 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.

USDA, Agricultural Marketing Service Science and Technology Programs PLANT VARIETY PROTECTION OFFICE		10301 Baltimore Avenue, Room 401 NAL Building Beltsville, Maryland, USA 20705 Office: (301) 504-5518 Fax: (301) 504-5291 General E-mail: PVPOmail@ams.usda.gov
RECORDATION FORM Recording assignment is any revisions of an assignment, or withdrawal or revocation of an assignment @ $41 per certificate/application
To the Commissioner of Plant Variety Protection: Please record the attached original documents or copy thereof.
1. Current Owner(s) of Record Name ____________________________________________ Address __________________________________________ _________________________________________________ _________________________________________________ Phone ___________________ FAX __________________ E-mail ____________________________________________	2. Type of Recordation (check all that apply) ____ Assignment ____ Security Interest, License, Grant, Conveyance ____ Merger ____ Change of Name of Owner(s) ____ Revocation of Assignment, Security Interest, License, Grant, or Conveyance ____ Change of Address of Owner(s) ____ Change of Representative (and address) ____ Change of Address of Representative ____ Change of Variety Name (Denomination) ____ Election of “Certified Seed Only” Option ____ Other (specify) ___________________________ Date Change went into Effect ____________________
3. New Owner(s) Name ____________________________________________ Address __________________________________________ _________________________________________________ _________________________________________________ Phone ___________________ FAX __________________ E-mail ____________________________________________	4. New Representative Name ____________________________________________ Address __________________________________________ _________________________________________________ _________________________________________________ Phone ___________________ FAX __________________ E-mail ____________________________________________
7. List PVP Number(s), Crop Kind(s), Variety Name(s). ATTACH LIST IF MORE SPACE IS NEEDED. [Please note that listed applications and certificates must be active. Recordations cannot be performed on inactive cases.]
8. Total number of applications/certificates involved: ______ Total Fee (97.175) ....................$_______________ Fees must be paid in U.S. funds. Make checks payable to “Treasurer of the United States.” Credit card payments.
9. Statement and Signature: To the best of my knowledge and belief, the foregoing information is true and correct and any attached copy is a true copy of the original document. _________________________________________ __________________________________­­­­­­______ ______________________ Name of Person Signing Signature Date

ST-473 (06/2012) designed by the Plant Variety Protection Office