NRC FORM 629 (02-21-2024)

AUTHORIZATION FOR PAYMENT 

BY CREDIT CARD

NRC FORM 629

(02-21-2024)

U.S. NUCLEAR REGULATORY COMMISSION

Estimated burden per response to comply with this voluntary collection request: 10 minutes. Requested 

information will allow respondents to transfer funds electronically. Send comments regarding burden 

estimate to the FOIA, Library, and Information Collections Branch (T-6 A10M), U.S. Nuclear Regulatory 

Commission, Washington, DC 20555-0001, or by email to Infocollects.Resource@nrc.gov, and the OMB 

reviewer at: OMB Office of Information and Regulatory Affairs, (3150-0190), Attn: Desk Officer for the 

Nuclear Regulatory Commission, 725 17th Street NW, Washington, DC 20503; email: 

oira_submission@omb.eop.gov. The NRC may not conduct or sponsor, and a person is not required to 

respond to, a collection of information unless the document requesting or requiring the collection displays a 

currently valid OMB control number.

APPROVED BY OMB: NO. 3150-0190 EXPIRES: 11/30/2026 

Effective October 1, 2024, the NRC will only accept electronic payment methods. Paper methods of 

payment, including NRC Form 629, will no longer be accepted. The NRC is currently accepting credit 

card payment of fees and other debts. The maximum amount accepted on a credit card per invoice is 

$24,999.99. Splitting of a payment on multiple credit cards is not allowed. If you wish to pay by credit card, 

complete the authorization below or at www.Pay.gov. If you have any questions, please contact the NRC's 

Fees Resource Help Desk at (301) 415-7554.

Date of Authorization Company Name of Licensee

Name of Cardholder Account Number Card Expiration Date

Address Cards Accepted (Check card you are using)

VISA MASTERCARD

NOVUS (DISCOVER) AMERICAN EXPRESS

Telephone Number License or Docket Number

Total Amount of Transaction Signature of Cardholder

U.S. Bank 

U.S. Nuclear Regulatory Commission 

Accounts Receivable Team 

P. O. Box 979051 

St. Louis, MO 63197-9000

If you are paying an application or registration fee (including new licenses, amendments, etc.), mail the completed form with 

your application to the appropriate regional office. For all other payments, send completed form to:

Email Address

Purpose of Payment:

Invoice (Number Required):

General License (Number Required):

New Application

Import/Export License

Reciprocity

Information Access Authorization Program (IAAP) 

Other (NRC Reference Number or Description) (Specify below):

*Note: Security Code is required *Security Code (3 Digits)

only if payment is submitted 

through www.Pay.gov
NRC FORM 629 (02-21-2024)

PRIVACY ACT STATEMENT 

NRC FORM 629 

AUTHORIZATION FOR PAYMENT BY CREDIT CARD

Pursuant to 5 U.S.C. 552a(e)(3), enacted into law by Section 3 of the Privacy Act of 1974 (Public Law 

93-579), the following statement is furnished to individuals who supply information to the U.S. Nuclear 

Regulatory Commission (NRC) on NRC Form 629. This information is maintained as part of a system of 

records designated as NRC-32 and described at 84 Federal Register 71559-71562 (December 27, 2019), 

or the most recent Federal Register publication of the NRC's "Republication of Systems of Records 

Notices" that is available in the NRC's Agencywide Documents Access and Management System 

(ADAMS).

1. AUTHORITY: 5 U.S.C. 552a; 5 U.S.C. 5514; 15 U.S.C. 1681; 26 U.S.C. 6103; 31 U.S.C. Chapter 37; 31 

U.S.C. 6501-6508; 42 U.S.C. 2201; 42 U.S.C. 5841; 31 CFR 900-904; 10 CFR Parts 15, 16, 170, 171; 

Executive Order (E.O.) 9397, as amended by E.O. 13478; and E.O. 12731. 

2. PRINCIPAL PURPOSE(S): To collect credit card account information and provide authorization for its 

use to collect a payment or debt.

3. ROUTINE USE(S): Information contained in this system may be disclosed to debt collection contractors 

or to other Federal agencies for the purpose of collecting and reporting on delinquent debts and to banks 

enrolled in the Automated Clearinghouse (ACH) Network to collect a payment or debt when the individual 

has given his or her authorization for this purpose. Information may be disclosed in accordance with any 

of the Routine Uses listed in the Prefatory Statement of General Routine Uses, including to an appropriate 

Federal, State, local or Foreign agency in the event the information indicates a violation or potential 

violation of law; in the course of an administrative or judicial proceeding; to an appropriate Federal, State, 

local and Foreign agency to the extent relevant and necessary for an NRC decision about you or to the 

extent relevant and necessary for that agency's decision about you; in the course of discovery under a 

protective order issued by a court of competent jurisdiction and in presenting evidence; to a Congressional 

office to respond to their inquiry made at your request; to NRC-paid experts, consultants, and others under 

contract with the NRC, on a need-to-know basis; and to appropriate persons and entities for purposes of 

response and remedial efforts in the event of a suspected or confirmed breach of data from this system of 

records.

4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF 

NOT PROVIDING INFORMATION: Providing this information is voluntary. However, not providing the 

requested information will not provide the NRC the information and authorization required to use your 

credit card to collect a payment or debt.

5. SYSTEM MANAGER(S) AND ADDRESS: Comptroller, Division of the Comptroller, Office of the Chief 

Financial Officer, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001.

AUTHORIZATION FOR PAYMENT 

BY CREDIT CARD (Continued)

NRC FORM 629

(02-21-2024)

U.S. NUCLEAR REGULATORY COMMISSION