1-786 Credit Card Payment Form

1-786 (06-01-2020)

OMB-1110-0070

CREDIT CARD PAYMENT FORM

*Denotes Required Fields

Name

* Name

(AS IT APPEARS ON CREDIT CARD)

Company Name (if applicable)

* Billing Address

Billing Address 2

* City

* State/Province

* Postal (zip) Code

* Country

*Credit Card #:

*Expiration Date (MM/YYYY)

* Security Code:

*Total Amount To Be Billed To Credit Card $

(____x $18 US Dollars Per Request)

*Card Holder Signature

Privacy Act Statement:

 Authority: The collection of your personally identifiable and financial information is authorized by 5 U.S.C. 301 and 28 C.F.R. 0.85, which establishes the FBI’s general administrative authority.

Purpose: The FBI will use this information to process the fee required for your request for your FBI identification record, as defined in 28 C.F.R.  16.30-16.34.

Routine Uses: The information you provide will be protected and the FBI may only share this information in accordance with the Privacy Act.

Disclosure: Provision of this information is voluntary; however, without it, the FBI may be unable to process the required fee.

Paperwork Reduction Act Statement:

This notice is given under the Paperwork Reduction Act of 1995. The Paperwork Reduction Act requires that the Federal Bureau of Investigation inform individuals and other entities of the following when asking for information. The information on this form will be utilized to make an electronic credit card payment in Pay.gov, which is owned and operated by the Department of Treasury, for the biometric and Identity History Services utilized to complete the request made on the respective Identity History Summary Request Form, 1-783. This fee is established pursuant to the provisions of 31 U.S.C. 9701 and is based upon the clerical time beyond the first quarter hour to be spent in searching for, identifying, and reproducing each Identification Record requested.

The estimate average burden associated with this collection is 2 minutes per respondent, depending on individual
circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to Department Clearance Officer, United States Department of Justice, Justice Management Division, Policy and Planning Staff, Washington, DC 20530.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number