Form PS2262 "Electronic Funds Transfer (Eft) Authorization" - Minnesota

What Is Form PS2262?

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

Form Details:

  • Released on December 1, 2015;
  • The latest edition provided by the Minnesota 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 PS2262 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Public Safety.

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Download Form PS2262 "Electronic Funds Transfer (Eft) Authorization" - Minnesota

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Print Form
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
445 Minnesota Street
Saint Paul, MN 55101-5188
Phone: (651) 205-4141 TTY: (651) 282-6555 Fax: (651) 797-1187
Web: dvs.dps.mn.gov
Electronic Funds Transfer (EFT) Authorization
• No Canadian Bank transfers; United States bank transfers only.
• To be completed by authorized signer, only.
• This is a one time authorization, not to be used for future transactions.
• If a fraud filter is on file with your bank, please notify your bank of the following company ID number:
DVS Fees: G416007162
U.S. Bank: E987654321
Indicate appropriate fees to be paid, the dollar amount authorized to be deducted from your bank account and the vehicle
identification number for the vehicle the fees are being applied to.
SELECT ONE:
IRP/IFTA fees for account number:
or
Vehicle Identification Number on permit:
Temporary registration or fuel permit fees
Fee amount authorized to be deducted:
Plus $1.50 EFT/ACH service fee payable to U.S. Bank
A $30 service charge is assessed on dishonored payments (Minn. Stat. section 604.112-113, Subd. 2)
Dishonored payments may result in suspension and/or revocation of your registration and the requirement of future
payments to be in the form of certified funds.
INFORMATION REQUIRED TO PROCESS EFT
Print bank account name (name printed on check) and provide copy of a voided check for bank account verification.
Name:
I certify that I am an authorized signer on the bank account listed below, with the authority to grant this authorization on behalf of the bank account
holder. I authorize Minnesota Department of Public Safety to initiate a one-time electronic debit entry to the account in payment of the current
taxes due. Once fees have been paid the payment cannot be cancelled.
Bank account authorized signature: __________________________________________________ Date:
EFT/ACH Debit Bank Information
Contact Information:
First Name:
Last Name:
Company:
Phone Number:
Street Address:
City/Town:
State:
Zip Code:
Payment Information:
Bank name:
Checking
Savings
Yes
No
Select account type:
Is this a business account?
Bank 9-digit routing number:
Bank account number:
Print Full Name of Authorized Signer:
(person signing to authorize fees to be deducted)
PS2262-02 (12/15)
Print Form
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
445 Minnesota Street
Saint Paul, MN 55101-5188
Phone: (651) 205-4141 TTY: (651) 282-6555 Fax: (651) 797-1187
Web: dvs.dps.mn.gov
Electronic Funds Transfer (EFT) Authorization
• No Canadian Bank transfers; United States bank transfers only.
• To be completed by authorized signer, only.
• This is a one time authorization, not to be used for future transactions.
• If a fraud filter is on file with your bank, please notify your bank of the following company ID number:
DVS Fees: G416007162
U.S. Bank: E987654321
Indicate appropriate fees to be paid, the dollar amount authorized to be deducted from your bank account and the vehicle
identification number for the vehicle the fees are being applied to.
SELECT ONE:
IRP/IFTA fees for account number:
or
Vehicle Identification Number on permit:
Temporary registration or fuel permit fees
Fee amount authorized to be deducted:
Plus $1.50 EFT/ACH service fee payable to U.S. Bank
A $30 service charge is assessed on dishonored payments (Minn. Stat. section 604.112-113, Subd. 2)
Dishonored payments may result in suspension and/or revocation of your registration and the requirement of future
payments to be in the form of certified funds.
INFORMATION REQUIRED TO PROCESS EFT
Print bank account name (name printed on check) and provide copy of a voided check for bank account verification.
Name:
I certify that I am an authorized signer on the bank account listed below, with the authority to grant this authorization on behalf of the bank account
holder. I authorize Minnesota Department of Public Safety to initiate a one-time electronic debit entry to the account in payment of the current
taxes due. Once fees have been paid the payment cannot be cancelled.
Bank account authorized signature: __________________________________________________ Date:
EFT/ACH Debit Bank Information
Contact Information:
First Name:
Last Name:
Company:
Phone Number:
Street Address:
City/Town:
State:
Zip Code:
Payment Information:
Bank name:
Checking
Savings
Yes
No
Select account type:
Is this a business account?
Bank 9-digit routing number:
Bank account number:
Print Full Name of Authorized Signer:
(person signing to authorize fees to be deducted)
PS2262-02 (12/15)