The 5017 Missouri form is an application used by individuals and businesses to establish an online account for filing Notices of Lien and accessing motor vehicle records. This form facilitates transactions such as lien filings and record access while allowing for direct debit payments. Completing this form is essential for those seeking to manage their motor vehicle-related transactions efficiently; click the button below to fill it out.
The 5017 Missouri form serves as an essential application for individuals and businesses seeking to establish or modify an online account with the Missouri Department of Revenue’s Motor Vehicle Bureau. This form enables users to file Notices of Lien, access motor vehicle and marine records, and set up direct debit for payments associated with these transactions. It consists of several sections that require careful completion, including details about the applicant, transaction types, and financial institution information. Applicants can indicate whether they are enrolling for the first time, changing existing account details, or canceling their debit authorization. Additionally, the form mandates the inclusion of a Security Access Code for those requesting access to sensitive records, ensuring compliance with privacy regulations. By providing accurate information and necessary documentation, such as a voided check, applicants can streamline their interactions with the Department and facilitate timely processing of their requests.
MISSOURI DEPARTMENT OF REVENUE
MOTOR VEHICLE BUREAU
PO BOX 2167, JEFFERSON CITY MO 65105-2167
(573) 526-3669 http://dor.mo.gov/mvdl
APPLICATION FOR ONLINE ACCOUNT
(NOTICE OF LIEN FILING/RECORDS ACCESS/DIRECT DEBIT)
SECTION A - APPLICATION/TRANSACTION TYPE - CHECK APPROPRIATE BOXES
FORM
5017
(REV. 8-2012)
APPLICATION TYPE
NEW
CHANGE
CANCEL
TRANSACTION TYPE(S) REQUESTED
ONLINE NOTICE OF LIEN FILING
ONLINE RECORD ACCESS
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
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 NAME
( )
FINANCIAL INSTITUTION ADDRESS (STREET, RR, OR PO BOX NUMBER)
ACCOUNT TYPE - CHECK ONLY ONE BOX
CHECKING
SAVINGS
GENERAL LEDGER
ROUTING NUMBER
DEPOSITOR (BUSINESS) ACCOUNT NUMBER
SECTION D - DIRECT DEBIT AUTHORIZATION - CHECK APPROPRIATE BOX.
A VOIDED CHECK OR DEPOSIT SLIP MUST BE ATTACHED.
I hereby authorize the Missouri Department of Revenue (Department) to initiate an electronic debit from the account identified above for payment of Notices of Liens processed and/or any records accessed online. I recognize that it is my responsibility to have the funds available in the account identified above for the withdrawal of my payment. I also understand that if the Department cannot deduct the payment from my account because funds are unavailable, I will be subject to overdraft fees from my financial institution. I will also be charged a dishonored payment penalty by the department. I further certify under penalties of perjury that I am authorized to sign this application and that any personal information obtained from any department records accessed will only be used as provided for in the federal Driver’s Privacy Protection Act.
I hereby cancel the authorization to electronically debit the account identified above.
SIGNATURE OF BUSINESS OWNER, PARTNER, CORPORATE OFFICER, OR INDIVIDUAL
PRINTED NAME OF BUSINESS OWNER, PARTNER, CORPORATE OFFICER, OR INDIVIDUAL TITLE OF BUSINESS OWNER, PARTNER, CORPORATE OFFICER, OR INDIVIDUAL
STAPLE VOIDED CHECK OR DEPOSIT SLIP HERE
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
CHECK NO.
HOMETOWN, USA
PAY TO THE ORDER OF ___________________________________
121456789
8765432109812
4444
R121456789
Routing No.
Dep. Acct. No.
Ck. 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:
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.
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