FORM FDA 3914 (07/22) Page 1 of 3 PSC Publishing Services (301) 443-6740 EF

Section A: Payment Information

Section B: Contact Information

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Food and Drug Administration

User Fee Payment Transfer Request

1. Date of Request (mm/dd/yyyy)

2. Payment Amount

4. Transfer Funds From

6. Transfer Amount

7. Transfer Reason (Please explain)

10. Contact Name 11. Contact Title/Position

3. Payment Reference Number

5. Transfer Funds To

13. Contact Email Address

Date of Signature (mm/dd/yyyy)

8. Organization Name

12. Contact Phone Number (Include area code)

15. Signature

14. ACKNOWLEDGEMENT: By signing this document I acknowledge that I am the official listed on this form, authorized to 

execute this request on behalf of my organization. Any questions regarding this request can be directed to me via the 

contact information provided.

Form Approved: OMB No. 0910-0805

Expiration Date: November 30, 2024

See PRA Statement on page 3.

9. Organization Address

Address 1 (Street address. No P.O. Boxes allowed)

Address 2 (Apartment, suite, unit, building, floor, etc.)

City

Country

State/Province/Region

ZIP or Postal Code

Section C: FDA Acknowledgement

16. FDA Received Date (mm/dd/yyyy) 17. Center Decision

20. Center Contact Name

(FDA Acknowledgement continued, next page)

18. If Denied, State Reason

19. Decision Date (mm/dd/yyyy)

Approved Denied
FORM FDA 3914 (07/22) Page 2 of 3

Section C: FDA Acknowledgement (Continued)

Instructions for Completing User Fee Payment Transfer Request – Form FDA 3914

1. Date of Request: Enter calendar date the form is

being completed.

2. Payment Amount: Enter the amount (in U.S.

Dollars) of the original payment.

3. Payment Reference Number: If payment was

remitted via check, money order or bank draft,

enter the check or money order number; if made

electronically via Automated Clearing House (ACH)

or credit card, enter the confirmation number; if

made via wire transfer, enter the trace or Input

Message Accountability Data (IMAD) number.

4. Transfer Funds From: Enter the Payment

Identification Number (PIN) or invoice number

where payment is coming from.

5. Transfer Funds To: Enter the PIN or invoice

number where payment is to be applied.

6. Transfer Amount: Enter the amount (in U.S.

Dollars) that is to be transferred.

7. Transfer Reason: Provide a brief description of

why funds are being transferred.

Section A: Payment Information

Section B: Contact Information

Form FDA 3914 is to be completed online at http://

www.fda.gov/forindustry/userfees/default.htm and is

to be used when requesting the transfer of user fee 

payments received by the FDA. If you need assistance 

in completing the form contact the User Fee Helpdesk 

via phone at (301) 796-7200 or email userfees@fda.

gov.

8. Organization Name: This is name of the

organization listed on the cover sheet or invoice.

Entry should match both old and new cover sheets

or invoices as listed in items 4 and 5.

9. Organization Address: Enter the following

elements of the organization address. 

Address 1 – Enter organization’s physical street

address. No P.O. Boxes are allowed.

Address 2 – As needed, enter apartment, suite,

unit, building, floor, etc.

City – Enter the city where organization is located.

State/Province/Region – Enter the state, province

or region where organization is located.

Country – Enter country where organization is

located.

ZIP or Postal Code – Enter zip code or postal

code of the organization’s location.

10. Contact Name: Enter the name of the person

requesting the transfer.

11. Contact Title/Position: Enter the position/title of

the person requesting the transfer.

12. Contact Phone Number: Enter the phone number

of the person requesting the transfer.

13. Contact Email Address: Enter the email address

of the person requesting the transfer.

14. Acknowledgement: Review acknowledgment,

confirming that you are the authorized

representative listed on this form and have

provided valid contact information in the event that

there are questions pertaining to the request.

15. Signature: Place signature of listed authorizing

official here.

Date of Signature – Date document is signed by

authorizing official.

Section C: FDA Acknowledgement

This section is for FDA use only. An FDA 

representative will fill out the following items:

16. FDA Received Date: Enter date that request was

received by FDA.

21. Request Executed? 22. If No, State Reason

23. Final Action 24. Date of Final Action (mm/dd/yyyy)

25. OFM Contact Name

Yes

Completed – Transferred Completed – Not Transferred

No

OFM Use Only
FORM FDA 3914 (07/22) Page 3 of 3

Instructions (Continued)

This section applies only to requirements of the Paperwork Reduction Act of 1995.

*DO NOT SEND YOUR COMPLETED FORM TO THE PRA STAFF EMAIL ADDRESS BELOW.*

The burden time for this collection of information is estimated to average 0.25 hours per response, including the 

time to review instructions, search existing data sources, gather and maintain the data needed and complete 

and review the collection of information. Send comments regarding this burden estimate or any other aspect 

of this information collection, including suggestions for reducing this burden, to:

Department of Health and Human Services 

Food and Drug Administration 

Office of Operations 

Paperwork Reduction Act (PRA) Staff 

PRAStaff@fda.hhs.gov

“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 number.”

17. Center Decision: Check appropriate box,

indicating if request was approved or denied.

18. If Denied, State Reason: If response to field 17

was “Denied”, provide reason.

19. Decision Date: Enter date decision was made.

20. Center Contact Name: Enter name of the Center’s

action officer.

21. Request Executed: Check the appropriate box,

indicating if request was executed.

22. If No, State Reason: If response to field 21 was

“No”, provide reason.

23. Final Action: Check the appropriate box, indicating

if request was transferred or not transferred.

24. Date of Final Action: Enter date that final action

was taken on request.

25. OFM Contact Name: Enter name of the OFM

action officer.