OST F 2770.3 Delphi eInvoicing User Account Application

OMB Control Number: 2105-0564
Expiration Date: 09/30/2017

U.S. Department of Transportation
Delphi eInvoicing System
User Account Application - Instructions

General Instructions
Purpose of Form
The enclosed form is used to confidently establish the identity
of an individual seeking to obtain a login into the DOT's
Delphi eInvoicing system. Because requests in this system
result in payments, security regulations mandate that each
individual maintain a login and secure password.
Who is eligible
Only staff members of registered DOT suppliers that have
authority to request payment of behalf of the supplier
organization are eligible.
Each Grantee or Supplier
organization must be registered in the Central Contractor
Registration (CCR) system. Any representative of a valid CCR
registered organization is eligible for system access.
How to apply
System access is by individual invitation only. Copies of this form
submitted without a unique invitation PIN number will not be
accepted. If you feel you need access to this system, contact your
DOT Grant Program Manager or Procurement (Contract) Officer.
How to obtain more information
You can contact the DOT Enterprise Services Center Helpdesk at
866-641-3500
or
405-954-3000,
or
email
at
DOTElectronicInvoicing@dot.gov.
Appeals Process
If your application for a login is not approved, you may send a letter
of appeal with a copy of the application to Director of the Office of
Financial Management, US Department of Transportation, Office of
Financial Management, B-30, room W93-322, 1200 New Jersey
Avenue
SE,
Washington
DC
20590-0001,
DOTElectronicInvoicing@dot.gov
Waiver Process
If you are unable to access the internet, or are otherwise unable to
use the DOT's Delphi eInvoicing system, your organization must
submit and be granted a waiver of compliance. Refer to DOT Form
2770.4 and related instructions for information regarding the waiver
process.

Mailing Instructions
Mail via certified USPS, UPS, Fedex, etc. to:
DOT Enterprise Services Center
FAA Accounts Payable, AMZ-100
PO Box 25710
Oklahoma City, OK 73125
Paperwork Reduction Act (44 U.S.C. 3501) Burden
Statement: A federal agency may not conduct or sponsor, and a
person is not required to respond to the requirements of the
Paperwork Reduction Act unless that collection of information
displays a currently valid OMB Control Number. The OMB
Control Number for this information collection is 2105-0564.
Public reporting for this collection of information is estimated to
be approximately 30 minutes per response, including the time
for reviewing instructions, searching existing data sources,
gathering and maintaining the data needed, completing and
reviewing the collection of information. All responses to this
collection of information are required to request grant related
payments from the DOT. Send comments regarding this
burden estimate or any other aspect of this collection, including
suggestions for reducing this burden to: Information Collection
Clearance Officer, Department of Transportation, 1200 New
Jersey Avenue SW, Washington, DC 20590, OST S-83.
Privacy Act Statement: Privacy Act Statement (5 U.S.C. §
552a, as amended): AUTHORITY: 31 USC 3512, authorizes DOT
to collect this information. PURPOSE(S): DOT will use the
information provided to establish your identify prior to your
receiving an account within our system, and is intended solely
to establish a unique identity and proof thereof. ROUTINE
USE(S): In accordance with DOT's system of records notice,
DOT/ALL 7 Departmental Accounting and Financial Information
System, DAFIS, the information provided may be disclosed to
“consumer reporting agencies” as defined in the Fair Credit
Reporting Act (15 U.S.C. 1681a(f)) or the Federal Claims
Collection Act of 1982 (31 U.S.C. 3701(a)(3)). DISCLOSURE:
Provision of the requested information is voluntary; however
failure to furnish the requested information may result in an
inability of the Department to grant you access to our system.

Notary Public Instructions
Please validate the identifying information provided on the form
against the photographic identity provided by the applicant. Verify
the ID number, name, address, and expiration date, and validate the
photo. You do not need to validate the PIN number.

OST F 2770.3

OPI: Office of Financial Management, B-30

OMB Control Number: 2105-0564
Expiration Date: 09/30/2017

U.S. Department of Transportation
Delphi eInvoicing System
User Account Application

Applicant Name:

Enter full legal name

Organization:

Enter the legal name of the organization you represent

Work Address:

Enter work street address including suite/room/mail routing

City:

Enter work city name

State/Province:

Enter work state/province name

Zip/Postal Code:

Enter work zip code or postal code

Work Phone:

Enter work phone number including extension

Work E-mail:

Enter work e-mail address (this will be your login)

Home Address:

Enter home street address (must match ID)

City:

Enter home city name

State/Province:

Enter home state/province name

Zip/Postal Code:

Enter home zip code or postal code
Identifying Information

The applicant must provide a Federal or State issued identification, such as a driver's license or passport. The identification must have
a photo that will be verified by the Notary Public.
Enter ID Number from presented Gov't issued identification
ID Number:
Issuing Authority

Enter the name of the Government Issuing Office

Expiration Date:

Enter the expiration date listed in the identification

Unique PIN:

Enter the unique 5-digit PIN from your e-mail invitation
Signatures

Applicant Signature

Affix Seal:

Mail via certified USPS, UPS, Fedex, etc. to:

Date

On this ______ day of ______________________ , 20____,
did personally appear before me
________________________________________________,
and presented identification as recorded herein. I have
verified the photo of the presenter of the identification, and
have verified the identifying information recorded herein,
verified that the recorded address matches the
identification, and witnessed their signature upon this form.

_________________________________ _______________
Notary Public
Commission Expires

DOT Enterprise Services Center
FAA Accounts Payable, AMZ-100
PO Box 25710
Oklahoma City, OK 73125
OST F 2770.3

OPI: Office of Financial Management, B-30