Form 0501 RCCD-003 "E-Check Payment Processing Request" - Nevada

What Is Form 0501 RCCD-003?

This is a legal form that was released by the Nevada Department of Public Safety - a government authority operating within Nevada. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2017;
  • The latest edition provided by the Nevada Department of Public Safety;
  • 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 0501 RCCD-003 by clicking the link below or browse more documents and templates provided by the Nevada Department of Public Safety.

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Download Form 0501 RCCD-003 "E-Check Payment Processing Request" - Nevada

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Records, Communications and Compliance Division
333 West Nye Lane, Suite 100
Carson City, Nevada 89706
Telephone (775) 684-6262 ~ Fax (775) 687-3232
www.rccd.nv.gov
E-Check Payment Processing Request
Unless otherwise noted all fields are required.
Incomplete forms will result in a delay to processing your payment.
Payment can be called into the Fiscal office at (775) 684-6237 or (775) 687-0172
or emailed to
ap@dps.state.nv.us
Company Name:
Account Number:
Brady
CNC
Civil Applicant
Payment Submitted by
(First Name Last Name):
Billing Address:
City, State, Zip
Telephone Number:
Ext.
Fax Number:
E-mail Address:
Physical Address:
City, State, Zip
Same as Billing
Payment Details
Payment Date is always the current date.
Account Holders are advised actual processing of
an E-check takes approximately 3 business days.
Payment Amount:
Payment Date:
Reference
:
(optional)
Name on Account:
Account Type:
Checking
Savings
Account Number:
Routing Number:
***There will be a $25.00 fee assessed on ALL returned checks/e-checks.**
Signature
Printed Name
Date
(required if form completed by the Account Holder)
For DPS – Records, Communications and Compliance Division Use ONLY
Statement Balance:
All information verified by:
Employee Initials
Date
0501RCCD-003(07/2017rev)
Records, Communications and Compliance Division
333 West Nye Lane, Suite 100
Carson City, Nevada 89706
Telephone (775) 684-6262 ~ Fax (775) 687-3232
www.rccd.nv.gov
E-Check Payment Processing Request
Unless otherwise noted all fields are required.
Incomplete forms will result in a delay to processing your payment.
Payment can be called into the Fiscal office at (775) 684-6237 or (775) 687-0172
or emailed to
ap@dps.state.nv.us
Company Name:
Account Number:
Brady
CNC
Civil Applicant
Payment Submitted by
(First Name Last Name):
Billing Address:
City, State, Zip
Telephone Number:
Ext.
Fax Number:
E-mail Address:
Physical Address:
City, State, Zip
Same as Billing
Payment Details
Payment Date is always the current date.
Account Holders are advised actual processing of
an E-check takes approximately 3 business days.
Payment Amount:
Payment Date:
Reference
:
(optional)
Name on Account:
Account Type:
Checking
Savings
Account Number:
Routing Number:
***There will be a $25.00 fee assessed on ALL returned checks/e-checks.**
Signature
Printed Name
Date
(required if form completed by the Account Holder)
For DPS – Records, Communications and Compliance Division Use ONLY
Statement Balance:
All information verified by:
Employee Initials
Date
0501RCCD-003(07/2017rev)