Fillable Printable Form G-1450
Fillable Printable Form G-1450
Form G-1450
Form G-1450 08/04/17 N
Page 1 of 1
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.
General Information
USCIS Privacy Act Statement
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.
Authorization for Credit Card Transactions
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form G-1450
OMB No. 1615-0131
Expires 08/31/2018
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.
Applicant's Information (Applicant's Full Legal Name)
Family Name (Last Name)Middle Name (if any)Given Name (First Name)
Credit Card Information
Credit Card Billing Information (Credit Card Holder's Name as it Appears on the Card)
Given Name (First Name) Middle Name (if any) Family Name (Last Name)
Credit Card Holder's Billing Address:
Street Number and Name
Apt. Flr. NumberSte.
City or Town State ZIP Code
Credit Card Holder's Signature and Contact Information:
Credit Card Holder's Daytime Telephone Number Credit Card Holder's Email Address
Credit Card Type:
Visa
Credit Card Number
Credit Card Expiration Date
(mm/yyyy)
MasterCard
American Express
Discover
Authorized Payment Amount
$
.00
Credit Card Holder's Signature
