Form Fm-138 - Authorization Agreement For Direct Deposits (Ach Debits/ Credits)
Download a blank fillable Form Fm-138 - Authorization Agreement For Direct Deposits (Ach Debits/ Credits) in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Fm-138 - Authorization Agreement For Direct Deposits (Ach Debits/ Credits) with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1AUTHORIZATION AGREEMENT FOR DIRECT DEPOSITS
(ACH DEBITS/ CREDITS)
Company
FINS Account
Name ___________________________________________ Number______________________________
I (we) hereby authorize New York State Department of Motor Vehicles to initiate Debit/Credit entries to my
(our) checking account indicated at the depository financial institution named below, hereafter called
Depository and to debit/credit the same to such account. I (we) acknowledge that the origination of ACH
transactions to my (our) account must comply with the provisions of United States law.
Should the Depository respond to an ACH with a notice of change, I (we) authorize the Department of Motor
Vehicles to update the account information, and to notify me (us) of the change.
Depository Name: _______________________________ Branch: ____________________________________
City: ______________________________________________ State: ________ Zip: __________ - _________
Routing
Account
Number: ________________________________________ Number: __________________________________
o
o
Personal Account
Business Account
This is a (please check one):
The account information stored at the Department of Motor Vehicles for the purposes of processing an ACH
transaction may be modified by me (us), and this agreement remains in effect with the new account
information.
This Authorization is to remain in full force and effect until New York has received written notification from
me (either of us) of its termination in such time and in such manner as to afford New York State Department
of Motor Vehicles and Depository a reasonable opportunity to act on it. Written notification of termination
ç
ç
Signature:
__________________________________
Signature:
__________________________________
Title: ______________________________________
Title: ______________________________________
(please print)
(please print)
Name:______________________________________
Name:______________________________________
(please print)
(please print)
ID number: __________________________________
ID number: __________________________________
(from driver’s license or ID card)
(from driver’s license or ID card)
State of driver’s license or ID: __________________
State of driver’s license or ID: __________________
Date (mm/dd/yyyy): __________________________
Date (mm/dd/yyyy): __________________________
FM-138 (7/15)
reset/clear
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dr 1011 - Authorization Agreement For Automatic Deposits (ach Credits) For Local Governments, Authorities And Districts
Financial
Authorization Agreement For Wire Deposits (ach Credits/debits) Form - Lawrence Livermore National Laboratory Finance Department
Legal
Related Categories
Parent category: Legal