Fillable Printable Tc-572, Business Application For Electronic Payments

Tc-572, Business Application For Electronic Payments

Division of Motor Vehicles · PO Box 30412, Salt Lake City, UT 84130 · Telephone 801-297-7780 or 1-800-368-8824

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Section 1 - Company Information

Company name

Street address

City

State

ZIP code

Telephone number Fax number

Email address

Federal EIN

Contact person Contact’s title

Bank name Routing number

Account number

Section 2 - Electronic Payment Information

Dealer 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 - Authorization

I authorize the Division of Motor Vehicles to charge my account through 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 financial institution. It is my responsibility to update the 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.

I further acknowledge the Division of Motor Vehicles reserves the right to apply charges without requiring my signed authorization for each transaction.

The Division of Motor Vehicles also 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 signature (read above statement) Title Date

Utah State Tax Commission

Business Application for Electronic Payments

TC-572

Rev. 5/16

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