AUTHORIZATION AGREEMENT FOR PREAUTHORIZED PAYMENTS
TC 95-586
Rev.2/08

COMPANY NAME

Registered Gross Vehicle Weight of heaviest vehicle: lbs. (Required)

 KYU NUMBER 
(Required if one has been issued)
DOT NUMBER
(Required)
I (we) hereby authorize The Commonwealth of Kentucky, hereinafter called The Commonwealth, to initiate debits entries to my (our) checking account indicated below and the depository named below, hereinafter called DEPOSITORY, to debit the same to such account.
Canadian banks not available for this service.
 
DEPOSITORY NAME  BRANCH
CITY        STATE      ZIP 

TRANSIT/ABA NO. 
CANADIAN BANKS NOT AVAILABLE FOR THIS SERVICE
 

ACCOUNT NO.  
                                      (Your Account #)
This authority is to remain in full force and effect until The Commonwealth and DEPOSITORY has received written notification from me (or either of us) of it's termination in such time and in such manner as to afford The Commonwealth and DEPOSITORY a reasonable opportunity to act on it.
NAME
 
(Applicant. Please print.)

SELECT YOUR PIN
(Must be 8 characters. May be letters,
numbers, or a combination of both.)

DATE     SIGNED  _______________________________________

PHONE NUMBER   FAX NUMBER

MAIL TO:  Division of Motor Carriers  PO Box 2007  Frankfort, KY 40602
FAX TO: 502-564-0992 Please include copy of voided check if faxing.

A VOIDED CHECK (OR A COPY OF A VOIDED CHECK) MUST ACCOMPANY THE COMPLETED FORM above to authorize the debit of your account for payment of Overweight/Overdimensional Permits and/or Combined 10 Day Temporary Permits.

Funds will be deducted the next banking day after a permit has been issued. Permits issued on a Thursday will be submitted for ACH debit on Friday. Permits issued on Friday will be submitted for ACH debit on Monday.

A brief explanation of the ACH debit process may be helpful to you. When you use a check to pay for something, your bank’s transit number and your account number (both of which are preprinted at the bottom of your check) tell which bank and account number your money is in so that bank can transfer the money into our account. This process allows us to keep these two numbers on file for you and process the transfer of money when you have obtained permits.

This process eliminates the need for you to fill out a check and deliver it to us. It eliminates the need for us to process your check and prepare a deposit slip for our bank. Finally, it eliminates the need for either of our banks to process your check. Your bank statement will actually show that the amount deducted was transferred to The Commonwealth of Kentucky and was for your payment of permits.

While you already provide us with this information four times a year when you send us your check, this information will be kept separate from your regular tax information in a secured location. Any changes to the password you selected or bank account number must be done in writing and will not be accessible through our normal call in procedures.