Clear form
Utah State Tax Commission
TC-572
Application for Utah DMV
Rev. 5/13
Payments Through Credit Card or Electronic Payment
Get forms online - tax.utah.gov
Division of Motor Vehicles · PO Box 30412, Salt Lake City, UT 84130
· Telephone
801-297-7780 or 1-800-368-8824
Section 1 - Company Information
Dealer number
Company name
Street address
City
State
ZIP code
Telephone number
Fax number
Email address
Federal EIN
Contact person
Contact’s title
Section 2 - Electronic Payment Information (if using electronic payment)
Account number
Bank name
Routing number
Name on bank account
Type of bank account
Foreign bank
Checking
Savings
Yes
No
NOTE: If your bank account is setup with a fraud filter, you will need to provide your bank with the company ID number of the
Utah State Tax Commission (USTC). Contact DMV Accounting at 801-297-7515 to obtain the USTC company ID number.
Section 3 - Credit Card Information (if using credit card)
Card type (Check one)
Visa
Discover
American Express
MasterCard
Card holder’s name
Card holder’s telephone number
State
ZIP code
Billing address
City
Expiration date (mo./yr.)
Card number
Authorization code
Section 4 - Authorization
I authorize the Division of Motor Vehicles to charge my account through the credit card or electronic payment shown above for the amount due for
services provided. I understand that any payments are based on current fees for title and registration processes.
My right to use this service is subject to any limits established by my credit card issuer or financial institution. It is my responsibility to
update the credit card or banking information that is used to pay for this service. I understand that I may notify the Division of Motor Vehicles
by written request at any time to terminate this authorization.
The Division of Motor Vehicles reserves the right to apply charges without requiring the customer’s signed authorization for each transaction.
Also, the Division of Motor Vehicles reserves the right to terminate this authorization agreement at any time.
By signing this application, I confirm all information is true and correct to the best of my knowledge.
Authorized or card holder’s signature (read above statement)
Title
Date
1
