Form 5295 - Ach Debit Application
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MISSOURI DEPARTMENT OF REVENUE
FORM
MOTOR VEHICLE AND DRIVER LICENSING DIVISION
5295
ACH DEBIT APPLICATION
(REV. 06-2010)
1. NAME OF APPLICANT
2. CONTACT PERSON
3. POSITION
4. APPLICANT’S ADDRESS
Street, P.O. Box Number
City
State
Zip
5. TELEPHONE NUMBER
6.
E-MAIL ADDRESS
7. FINANCIAL INSTITUTION NAME
8.
TELEPHONE NUMBER
( __ __ __ ) __ __ __ - __ __ __ __
9. FINANCIAL INSTITUTION ADDRESS
Street, P.O. Box Number
City
State
Zip
10. APPLICANT’S ACCOUNT INFORMATION
ABA Routing Number
Account Number
11. CHECK APPROPRIATE BOX
J
I hereby authorize the Missouri Department of Revenue (department) to initiate
an electronic debit from the account identified above for payment of license fees.
I recognize that it is my responsibility to have the funds available in the account
identified above for the withdrawal of my payment. I also understand that if the
department cannot deduct the fee/penalty from my account because funds are
unavailable, I will be subject to overdraft fees from my financial institution. I will
also be charged a dishonored payment penalty by the department.
J
I hereby cancel the authorization to electronically debit the account identified
above.
12. SIGNATURE OF APPLICANT
13. PRINTED NAME OF APPLICANT
DOR-5295 (06-2010)
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