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

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

Form PSB-2 - Sample Receipt Form - New York

Form PSB-2 - Sample Receipt Form - New York

Commissioners 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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