Authorization for Credit Card Transactions Department of Homeland Security U.S. Citizenship and Immigration Services General Information USCIS Form G-1450 OMB No. 1615-0131 Expires 08/31/2018 Complete the "Applicant's Information," "Credit Card Billing Information," and "Credit Card Information" sections and sign the authorization. U.S. Citizenship and Immigration Services (USCIS) cannot process credit card payments without an authorized signature. Failure to provide the requested information may result in USCIS and your financial institution not accepting the payment. USCIS Privacy Act Statement AUTHORITIES: The information requested on this authorization, and the associated evidence, is collected under section 286(m) of the Immigration and Nationality Act, 8 U.S.C. 1356(m). PURPOSE: The primary purpose for providing the requested information is to authorize the USCIS Lockbox to make an electronic credit card payment in Pay.gov, which is owned and operated by the Department of Treasury, for the filing fee and biometric services fee associated with a benefit request form. USCIS will process your case when the payment is received in full. DISCLOSURE: The information you provide is voluntary. However, failure to make a payment towards the associated benefit request filing fee and biometric services fee may delay or prevent USCIS from accepting your benefit request form. ROUTINE USES: This information may be used by and disclosed to USCIS personnel and contractors or other agents who need the information to assist in activities related to processing associated fees. Additionally, USCIS may disclose the information to other Federal, state, local, and authorized organizations in accordance with approved routine uses, as described in the associated published system of records notice [TREASURY/FMS.017 - Collections Records --Treasury/Financial Management Service, which can be found at http://www.treasury.gov/privacy, and DHS-USCIS-007 - Benefits Information System, available at www.dhs.gov/privacy]. The information may also be made available, as appropriate, for law enforcement purposes or in the interest of national security. Paperwork Reduction Act An agency may not conduct or sponsor an information collection, and a person is not required to respond to a collection of information, unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 5 minutes per response, including the time for reviewing instructions and completing and submitting the authorization. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Coordination Division, Office of Policy and Strategy, 20 Massachusetts Ave, NW, Washington, DC 20529-2140; OMB No. 1615-0131. Do not mail your completed Form G-1450 to this address. Applicant's Information Applicant's Full Legal Name: Given Name (First Name) Middle Name (if any) Family Name (Last Name) Credit Card Billing Information Credit Card Holder's Name as it appears on the card: Given Name (First Name) Credit Card Holder's Billing Address: Street Number and Name City or Town Credit Card Holder's Contact Information and Signature: Credit Card Holder's Email Address Credit Card Holder's Signature Credit Card Holder's Daytime Telephone Number Apt. Ste. Flr. State Number ZIP Code Middle Name (if any) Family Name (Last Name) Credit Card Information Credit Card Type: Credit Card Number Visa MasterCard American Express Discover Credit Card Expiration Date (mm/yyyy) Form G-1450 08/06/15 Authorized Payment Amount $ .00 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com