Form FDA 3601(a) FDA 3601(a) Device Facility User Fee

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Form Approved: OMB No. 0910-0511 Expiration Date: August 31, 2022. See Instructions for OMB Statement.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOOD AND DRUG ADMINISTRATION
DEVICE FACILITY USER FEE

PAYMENT IDENTIFICATION NUMBER:
Include the Payment Identification Number (PIN) with payment.

The following actions must be taken to properly submit your payment:
1. To submit payment, please select one of the following options:
A. To pay electronically using ACH (electronic check from a US bank) or a credit card, please select the “Pay Now” option.
B. To pay using a check drawn on a US bank in US dollars, please follow these instructions:
•
Make check payable to the Food and Drug Administration
•
Write the payment identification number (PIN) on the check
•
Mail check and a printed copy of the order to:
Food and Drug Administration
P.O. Box 979108
St. Louis, MO 63197-9000
OR
•
For checks sent by courier, mail the check and printed copy of the order to:
Attn: ATTN: Government Lockbox 979108
1005 Convention Plaza
St. Louis, MO 63101
Note: This U.S. Bank address is for courier delivery only; do not send mail to this address.
C. To pay by wire transfer, please read the following:
You are responsible to pay any administrative costs associated with the processing of a wire transfer. Contact your bank or
financial institution regarding the additional fees.
US Department of Treasury
TREAS NYC
33 Liberty Street
New York, NY 10045
FDA Deposit Account Number: 75060099
Beneficiary: Food and Drug Administration, OFM Division of User Fees Powder Mill 62143
12225 Wilkins Avenue Rockville, MD 20852.
US Department of Treasury routing/transit number: 021030004
SWIFT Number: FRNYUS33
You must include the user fee payment identification number (PIN), and ensure that the fee that your bank will charge for the wire
transfer is added to your fee payment.
2. Company Name and Address

3. Contact Name
3.1 E-mail Address
3.2 Telephone Number
3.3 Fax Number

2.1 Employer Identification Number (EIN)
4. PIN-PCN (Payment Identification Number-Payment Confirmation Number):

5. Amount Due:
$
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Form FDA 3601(a)

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8/16/2021