FV-387 Alternate Payment Application

OMB 0581-NEW

Agricultural Marketing Service, Fruit & Vegetable Program, Specialty Crops Inspection Division

Alternate Payment Application

To set up an alternate payment method with Specialty Crops Inspection (SCI) Division using a credit card or an electronic check, please fill out this application and mail it back to the address below.

Company Name:
Account Number:
Address:
City, State, Zip:
Contact’s Phone:					Contact’s Email:
	Yes, I would like to have the option to pay for goods and/or services by credit card.
	Select Credit Card:			American Express			Master Card		Diners Club/Cart Blanche
				Discover			Visa
	Number on Credit Card:
	Expiration Date of Credit Card:
	Name as shown on Credit Card:
	Security Code :

The security code is found on the back side of the credit card and is usually the characters that follow the credit card number. For a SCI Division alternate payment plan, the SC I Division will need this code. If you wish to call in your payment, you can give the code over the telephone to the Payment Center.

	Yes, I would like to have the option to pay for goods and/or services by electronic check.
	Bank Routing Number:
	Checking Account Number:

	Yes, I would like to set up a SCI Division Auto Pay payment plan.
	Select a payment method SCI Division should use in Auto Pay plan.		Credit Card		Electronic Check
	Payment Date (Day of Month):

By signing this application, I authorize the United States Department of Agriculture, Agricultural Marketing Service, Fruit and Vegetable Program, Specialty Crops Inspection Division to use the above information for the purpose of payment toward goods and/or services provided by the Specialty Crops Inspection Division.

If the SCI Division Auto Pay plan has been selected, I agree to allow the SCI Division Payment center to apply payments toward my current billed amount using the specified payment plan selected above. I acknowledge that insufficient funds will result in the cancellation of this program. I am aware that at any time I may cancel any or all of the payment plans. Transactions are through Pay.gov, a secure payment transaction source.

Applicant’s Signature

Print Name

Return application to:

Attn: Payment Center

USDA, AMS, FV, SCI Div.

2202 Monterey St, Ste 102-A

Fresno CA 93721-3175

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 five minutes 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.

FV-387 (10-2015)

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

1. mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410;

2. fax: (202) 690-7442; or

3. email: program.intake@usda.gov.

USDA is an equal opportunity provider, employer, and lender.

FV-387 (10-2015)