Form 5017 Missouri – Fill Out and Use This PDF

SECTION B - BUSINESS AND CONTACT PERSON INFORMATION - PLEASE TYPE OR PRINT USING A BALL POINT PEN.

SEE INSTRUCTIONS ON REVERSE SIDE.

BUSINESS

CONTACT PERSON

NAME OF BUSINESS OR INDIVIDUAL

CONTACT PERSON’S NAME (LAST, FIRST, MIDDLE)

IDENTIFICATION NUMBER

CONTACT PERSON’S ADDRESS (STREET, RR, OR PO BOX NUMBER)

SEE INSTRUCTIONS ON BACK

BUSINESS OR INDIVIDUAL’S ADDRESS (STREET, RR, OR PO BOX NUMBER)

CITY

STATE

ZIP CODE

CITY

STATE

ZIP CODE

E-MAIL ADDRESS

TELEPHONE NUMBER

(

)

SECURITY ACCESS CODE (DPPA NUMBER) - COMPLETE IF APPLYING FOR ONLINE RECORD

TYPE OF BUSINESS

ACCESS.

BANK

TITLE LOAN

INDIVIDUAL

SAVINGS AND LOAN

CREDIT UNION

DEALER FILING AS LIENHOLDER

DEALER FILING FOR A LIENHOLDER

DEPARTMENT USE ONLY

TOWER (NO CHARGE FOR ONLINE RECORD ACCESS - DO NOT COMPLETE SECTION C OR SECTION D)

OTHER ___________________________________________________________________________________

SECTION C - ACCOUNT INFORMATION - COMPLETE ONLY IF NEW APPLICATION OR CHANGING ACCOUNT INFORMATION.

FINANCIAL INSTITUTION ADDRESS (STREET, RR, OR PO BOX NUMBER)

ACCOUNT TYPE - CHECK ONLY ONE BOX
CHECKING	SAVINGS	GENERAL LEDGER

SECTION D - DIRECT DEBIT AUTHORIZATION - CHECK APPROPRIATE BOX.

A VOIDED CHECK OR DEPOSIT SLIP MUST BE ATTACHED.

DOR-5017 (8-2012)

PLEASE READ THIS INFORMATION CAREFULLY

COMPLETION INSTRUCTIONS

1.To apply for an online account to file Notices of Lien and/or access motor vehicle and marine records and have the payment for such transactions direct debited, complete this form as follows:

General Instructions

•Complete Sections A, B, C, and D if you are enrolling for the first time, re-enrolling after cancellation, changing your existing debit authorization, or other information. If you are a tower, do not complete Sections C and D when requesting online record access only.

•If you are cancelling your debit authorization, complete Sections A, B, and D only.

Section A - Application/Transaction Type

•Application Type - Check the appropriate box.

1.New - Complete for new enrollment or re-enrollment after cancellation.

2.Change - Complete to change type of account, financial institution or branch routing number, depositor (business) account number, or other information.

3.Cancel - Complete to cancel your debit authorization.

•Transaction Type(s) Requested - Check the appropriate box(es).

Section B - Business and Contact Person Information

•Complete all blocks for both the business or individual and contact person information.

•Security Access Code - This code is issued by the Motor Vehicle Bureau to entities who qualify under the Driver’s Privacy Protection Act to receive personal information contained in the department’s vehicle and marine records. If you indicate you would like online record access in Section A - Transaction Type(s) Requested, you must enter the Security Access Code. If you do not have a Security Access Code, you may apply by completing a Request for MV/DL Record(s)/Security Access Code (DOR-4678). The application can be obtained from any local contract office.

•Identification Number - Please record the FDIC number (bank), NCUA number (credit union), Dealer number (licensed motor vehicle/boat dealer), FEIN (any other type of business), or SSN (individual) as the identification number. The last six blocks are for Department of Revenue use only.

•Type of Business - Check the appropriate box.

Section C - Account Information

•Financial Institution Information - Record the financial institution’s name, telephone number, address, city, state, and zip code.

•Account Type - Check the appropriate box.

•Routing Number - Your financial institution’s routing number is printed on the bottom left-hand portion of your business or personal checks or deposit tickets (the first 9 digits). See examples 1 and 2 below.

•Depositor (Business) Account Number - Your depositor account number is printed on the bottom of your business or personal

checks following the routing number. It may be the first series of digits after the routing number followed by the check number

(example 1), or it may be the series of digits which follow the check number (example 2). NOTE: Check number is not included in the depositor account number.

	Example 1				Example 2
	XYZ BUSINESS		CHECK NO. 4444		XYZ BUSINESS		CHECK NO.
	HOMETOWN, USA				HOMETOWN, USA
	PAY TO THE ORDER OF ___________________________________				PAY TO THE ORDER OF ___________________________________
	121456789	8765432109812	4444		R121456789	4444	8765432109812
	Routing No.	Dep. Acct. No.	Ck. No.		Routing No.	Ck. No.	Dep. Acct. No.

NOTE: Credit unions and savings and loan associations may differ from the above examples. Please verify your depositor account number and electronic routing number with your financial institution.

Section D - Direct Debit Authorization

•Check appropriate box. Attach a voided business or personal check or deposit slip to the front right-hand side of this application. This is necessary to verify the depositor account number, routing number, and financial institution.

2.Submit the completed application to the following address:

MOTOR VEHICLE BUREAU

PO BOX 2167

JEFFERSON CITY MO 65105-2167

CHANGE FINANCIAL INSTITUTION OR DEPOSITOR ACCOUNT INFORMATION

Debits (withdrawals) will continue to be made from the designated account at your financial institution until the Missouri Department of Revenue is notified that you wish to redesignate your account and/or financial institution. To redesignate, complete and submit a new Application for Online Account (Notice of Lien Filing/Records Access/Direct Debit) with the new information.

DOR-5017 (8-2012)