Form FM-138 "Authorization Agreement for Direct Deposits (ACH Debits/ Credits)" - New York

What Is Form FM-138?

This is a legal form that was released by the New York State Department of Motor Vehicles - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2015;
  • The latest edition provided by the New York State Department of Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form FM-138 by clicking the link below or browse more documents and templates provided by the New York State Department of Motor Vehicles.

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Download Form FM-138 "Authorization Agreement for Direct Deposits (ACH Debits/ Credits)" - New York

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AUTHORIZATION AGREEMENT FOR DIRECT DEPOSITS
(ACH DEBITS/ CREDITS)
Company
FINS Account
Name
Number
I (we) hereby authorize New York State Department of Motor Vehicles to initiate Debit/Credit entries to my
(our) checking account indicated at the depository financial institution named below, hereafter called
Depository and to debit/credit the same to such account. I (we) acknowledge that the origination of ACH
transactions to my (our) account must comply with the provisions of United States law.
Should the Depository respond to an ACH with a notice of change, I (we) authorize the Department of Motor
Vehicles to update the account information, and to notify me (us) of the change.
Depository Name:
Branch:
City:
State:
Zip:
­
Routing
Account
Number:
Number:
Personal Account
Business Account
This is a (please check one):
The account information stored at the Department of Motor Vehicles for the purposes of processing an ACH
transaction may be modified by me (us), and this agreement remains in effect with the new account
information.
This Authorization is to remain in full force and effect until New York has received written notification from
me (either of us) of its termination in such time and in such manner as to afford New York State Department
of Motor Vehicles and Depository a reasonable opportunity to act on it. Written notification of termination
of authorization must be mailed to Revenue Accounts, PO Box 2409. Albany, NY 12220-0409.
X
X
Signature:
Signature:
Title:
Title:
(please print)
(please print)
Name:
Name:
(please print)
(please print)
ID number:
ID number:
(from driver’s license or ID card)
(from driver’s license or ID card)
State of driver’s license or ID:
State of driver’s license or ID:
Date (mm/dd/yyyy):
Date (mm/dd/yyyy):
FM-138 (7/15)
AUTHORIZATION AGREEMENT FOR DIRECT DEPOSITS
(ACH DEBITS/ CREDITS)
Company
FINS Account
Name
Number
I (we) hereby authorize New York State Department of Motor Vehicles to initiate Debit/Credit entries to my
(our) checking account indicated at the depository financial institution named below, hereafter called
Depository and to debit/credit the same to such account. I (we) acknowledge that the origination of ACH
transactions to my (our) account must comply with the provisions of United States law.
Should the Depository respond to an ACH with a notice of change, I (we) authorize the Department of Motor
Vehicles to update the account information, and to notify me (us) of the change.
Depository Name:
Branch:
City:
State:
Zip:
­
Routing
Account
Number:
Number:
Personal Account
Business Account
This is a (please check one):
The account information stored at the Department of Motor Vehicles for the purposes of processing an ACH
transaction may be modified by me (us), and this agreement remains in effect with the new account
information.
This Authorization is to remain in full force and effect until New York has received written notification from
me (either of us) of its termination in such time and in such manner as to afford New York State Department
of Motor Vehicles and Depository a reasonable opportunity to act on it. Written notification of termination
of authorization must be mailed to Revenue Accounts, PO Box 2409. Albany, NY 12220-0409.
X
X
Signature:
Signature:
Title:
Title:
(please print)
(please print)
Name:
Name:
(please print)
(please print)
ID number:
ID number:
(from driver’s license or ID card)
(from driver’s license or ID card)
State of driver’s license or ID:
State of driver’s license or ID:
Date (mm/dd/yyyy):
Date (mm/dd/yyyy):
FM-138 (7/15)