You must mail the original completed user agreement to us at:
Alcohol and Tobacco Tax and Trade Bureau (TTB)
550 Main Street, Room 8002
Cincinnati, OH 45202
Attn: Pay.gov
Appendix 1: D
efinitions:
1. Agreement: This written agreement between TTB and the User.
2. Automated Electronic Payments: A Payment by electronic funds transfer using the Automated Clearing House
payment system.
3. Internal Revenue Code: Title 26 United States Code
4. Internet: The global computer network comprising interconnected networks using standard protocols.
5. Password: The verification used by the Pay.gov system to permit access by an identified username.
6. Pay.gov: The government’s electronic payment system running on a computer connected to the Internet to
process and submit forms.
7. System Access Request Form: A form prescribed by TTB for gathering personal identification data with regard
to each individual authorized to act on behalf of the User Company in the use of the Pay.gov System.
8. Username: The identification used to determine authorization, authority, and privileges for use of the Pay.gov
system by the individual to whom access permission has been granted.
9. User: Person with Signature Authority or Power of Attorney for a User Company that will use the Pay.gov system
to submit forms and/or payments to TTB. Note: Users may enter data for multiple User Companies.
10. User Company: Entity that has dealings with Alcohol and Tobacco Tax and Trade Bureau.
11. Reassign User: Person without Signature Authority or Power of Attorney that will enter data into the Pay.gov
system for a User Company. They then reassign the completed forms to a User for submission.
12. TTB: The Alcohol and Tobacco Tax and Trade Bureau
TTB USE ONLY
Signature
Name
Director, National Revenue Center
Title
Signature
Name
Chief, National Revenue Center
Title
PAPERWORK REDUCTION ACT NOTICE
This request is In accordance with the Paperwork Reduction Act
of 1995. We use this information collection to identify, validate,
approve, and register qualified users to allow for submission of
electronic forms using the Pay.gov System. The information we
request is voluntary but is required for enrollment in this program.
We estimate the average burden associated with this collection
of information is 5 minutes per respondent or record keeper,
depending on your individual circumstances. Address your
comments concerning the accuracy of this burden estimate and
suggestions to reduce this burden to Reports Management
Officer, Regulations and Procedures Division, Alcohol and
Tobacco Tax and Trade Bureau, 1310 G Street, NW, Box 12,
Washingt
on, DC 20005. An agency may not conduct or sponsor,
and an individual is not required to respond to, a collection of
information unless it displays a currently valid OMB control number.
PRIVACY ACT STATEMENT
We provide this information to comply with Section 3 of the Privacy Act
of 1974 (5 U.S.C. 552(a)(e)(3)). We request this information under the
authority of 27 CFR Chapter 1 Part 73 Subpart C, and 26 U.S.C.- 6011,
6061, and 7502. The information requested is used to identify, validate,
approve, and register qualified users to allow for submission of
electronic forms using the Pay.gov System. We use this information to
make determinations for the purposes described in paragraph 2. Also
we may disclose the information to other Federal, State, foreign, and
local law enforcement and regulatory agency personnel to verify
information on the form where law does not prohibit such disclosure. We
may disclose the information to the Justice Department if it appears that
the furnishing of false information may constitute a violation of Federal
law. Finally, we may disclose the information to members of the public in
order to verify information on the form where law does not prohibit such
disclosure. If you fail to supply complete information, there will be a
delay in our approval of your participation in this program.
TTB F 5000.31 (04/2012)
