According to the Paperwork Reduction Act of 1995, no persons are 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 0579-0055. The time required to complete this information 

collection is estimated to average .25 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.

OMB Approved

0579-0055

UNITED STATES DEPARTMENT OF AGRICULTURE

ANIMAL AND PLANT HEALTH INSPECTION SERVICE APPLICATION FOR CREDIT ACCOUNT

1. ACCOUNT TYPE (check applicable blocks)

VETERINARY SERVICES USER FEE PLANT PROTECTION AND QUARANTINE 

REIMBURSABLE OVERTIME

OTHER SERVICES (specify):

2. APPLICANT NAME AND TITLE 3. FIRM NAME (As shown in Box 1 of your attached W9) 4. DATE BUSINESS STARTED

5. BILLING ADDRESS 6. PHYSICAL LOCATION ADDRESS

7. TELEPHONE NUMBER 8. FAX NUMBER 9. EMAIL ADDRESS

10. ACCOUNT CONTACT NAME(S)

11. PRINCIPAL OFFICER(S) AND/OR OWNER(S) INFORMATION

OFFICER OR OWNER OFFICER OR OWNER OFFICER OR OWNER

NAME

TITLE

HOME ADDRESS

TELEPHONE NUMBER

12. LIST OTHER TRADE NAMES, SUBSIDIARIES, BRANCHES, DIVISIONS, PARENTS, ETC.

13. ORGANIZATION TYPE

INDIVIDUAL PARTNERSHIP CORPORATION COLLEGE OR 

UNIVERSITY

STATE 

GOVERNMENT

FEDERAL 

GOVERNMENT 

AGENCY

OTHER (specify):

14. NUMBER OF EMPLOYEES 15. DO YOU OWN OR RENT YOUR BUILDING? 16. IF RENTING, PROVIDE LANDLORD INFORMATION

OWN NAME:

RENT TELEPHONE NUMBER:

17. IRS TAX IDENTIFICATION NUMBER OR APPLICANT’S SOCIAL SECURITY NUMBER (check one and provide the number. If not provided, credit will not be issued.)

TAX ID NUMBER

SOCIAL SECURITY NUMBER

18. FORMER BUSINESS LOCATION(S) FOR THE PAST SEVEN YEARS

PRIVACY ACT STATEMENT

Section 552 of Title 5 to the U.S. Code authorizes collection of this information. The primary use of this information is to gather data that will be used to establish a credit 

account for the purchase of goods and services from the Animal and Plant Health Inspection Service. User fees are authorized by Section 2509(c)(1) of the Food, Agriculture, 

Conservation and Trade Act of 1990, amended by the Omnibus Budget Reconciliation Act of 1990, referred to as the 1990 Farm Bill, (21 U.S.C. 136 and 136a and 21 U.S.C. 

135). Information collected will be used by Federal employees who have a need for the information in the performance of their official duties. Additional disclosures of this 

information may be made to Federal, State, local, or foreign agencies in relation to investigations of civil, criminal, or regulatory investigations or prosecutions, to the court of 

competent jurisdiction, to the United States Department of Agriculture's office of Inspector General's Office in connection with user fees reviews, and to consumer reporting 

agencies in accordance with Section 3711 (f) of Title 31.

Your social security account number is solicited under the authority of the Internal Revenue Code (26 U.S.C. 6011 (b) and 6109) and Executive Order 9397, November 22, 

1943, for use as a taxpayer and/or employee identification number. Disclosure of your social security number and other requested information is voluntary; however, failure to 

provide the information may result in disapproval of your request for credit.

APHIS FORM 192 Previous editions are obsolete.

SEP 2020
19. CURRENT BANK ACCOUNT INFORMATION

CHECKING ACCOUNT SAVINGS ACCOUNT

NAME OF FINANCIAL 

INSTITUTION

ADDRESS

TELEPHONE NUMBER

FAX NUMBER

YEARS ACCOUNT OPEN

20. BUSINESS OR PROFESSIONAL CREDIT REFERENCES (list 3)

REFERENCE 1 REFERENCE 2 REFERENCE 3

NAME

ADDRESS

TELEPHONE NUMBER

FAX NUMBER

21. APHIS LOCATIONS TO BE NOTIFIED OF THE ACCOUNT NUMBER

AGREEMENTS

This information contained in this application is for the purpose of obtaining credit and is warranted to be true. I/We hereby authorize the agency to whom this application is 

made to investigate the information given herein pertaining to my/our credit and financial responsibilities. I/We have used services 6 times, plan on continuing to use services 

6 times per year, and do not already have an account under this Federal Tax ID Number.

It is hereby agreed that the USDA APHIS will be reimbursed by the applicant upon completion of services. Payment will be made at the rate(s) established for services in 

accordance with 7 CFR Part 354 and 9 CFR Parts 97 and 130.

If the account becomes past due it will be placed in a cash on delivery (COD) basis requiring payment at the time of service.

A current IRS Form W-9 is attached to the completed application; I/we acknowledge an incomplete application may delay establishing an account.

Applicants’ signatures attest understanding, financial responsibility, authority, ability and willingness to pay all debts, interest, penalties, and administrative costs.

22. SIGNATURE NAME(S) AND TITLE(S) 23. AUTHORIZED SIGNATURE(S) (seals) 24. DATE

25. REMARKS

To protect the sensitive information in this application,

it is recommended this form and attachments be emailed to ABSHelpline@usda.gov.

Otherwise, use accountable mail or a similar service to send the packet to

USDA APHIS FMD FOB, Attn: APHIS ARS Team, 250 Marquette Ave, Suite 410, Minneapolis, MN 55401.

For customer service inquiries, please call (877) 777-2128.

FOR OFFICIAL USE ONLY

26. ACCOUNT NUMBERS ASSIGNED 27. APPROVING ANALYST 28. DATE

APHIS FORM 192 (REVERSE)