Fillable Printable Form PSB-2 - Sample Receipt Form - New York

Form PSB-2 - Sample Receipt Form - New York

Commissioner’s Regulations require a Private Service Bureau to issue a receipt for all services. You

must attach a copy of the receipt you will be using to your application. The sample receipt below

contains all of the items that are required.

XXX PRIVATE SERVICE BUREAU, INC.

123 Main Street

Anytown, NY 13064

(518) 555-5123

Date: _________________

Received from: ________________________________________

Address: ______________________________________________

The sum of ______________ Dollars

DMV Fee for

Services Provided

Fee Service

Obtaining Plates $____________ $ ____________

Sales Tax $____________ $ ____________

Transfer of Vehicle $____________ $ ____________

Duplicate Title $____________ $ ____________

Duplicate Registration $____________ $ ____________

Road Test Appt. $____________ $ ____________

Other:_______________ $____________ $ ____________

TOTAL $____________ $ ____________

Received by: __________________________________________

This is a licensed Private Service Bureau, but is not an official

agency of the Department of Motor Vehicles, State of New York

FAX (518) 555-1234

00001

Receipt #: ______________

SAMPLE RECEIPT FORM

PSB-2 (10/15)

If this is an assumed

name and the business

is owned by an

individual or

partnership, the

name(s) of the owner(s)

must appear below the

name of the business.

Must be

numbered

consecutively.

These are only

examples of

services. List the

services you

commonly

perform.

This is the total

amount received

from the

customer. Include

the DMV fees

and fees for your

services.

Wording of

this statement

must be

exactly as

printed here.

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