Form 5017 - Application for Online Account (Notice of Lien Filing, Records Access, and Direct Debit)

Section C

Account Information

Complete only if new application or changing account information. See page 2 for instructions.

An original voided check, deposit slip, or letter from financial institution must be attached.

Financial Institution Name Telephone Number

(___ ___ ___)___ ___ ___–___ ___ ___ ___

Financial Institution’s Address City State Zip Code

Account Type - Select only one box.

Checking

Savings

General Ledger

Routing Number Depositor (Business) Account Number

r 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 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.

r I hereby cancel the authorization to electronically debit the account identified above.

Department Use Only

Mail to: Motor Vehicle Bureau

P.O. Box 3355

Jefferson City, MO 65105-3355 Phone: (573) 526-3669

Visit

https://dor.mo.gov/motorv/liendeal/

for additional information.

Form 5017 (Revised 02-2019)

Validation Area

Section A

Type

Application or Transaction Type - Select Appropriate Boxes

Application Type Transaction Type(s) Requested

r New r Change r Cancel r Online Notice of Lien Filing r Online Record Access

Security Access Code - Complete if

applying for online record access.

(DPPA Number)

Section B

Business and Contact Person

Business

Name of Business or Individual Identification Number - See instructions on back.

Business or Individual’s Address City State Zip Code

Contact Person

Contact Person’s Name (Last, First, Middle)

Contact Person’s Address City State Zip Code

E-mail Address Telephone Number

(___ ___ ___)___ ___ ___–___ ___ ___ ___

Type of Business

r Bank or Savings and Loan r Credit Union r Dealership Filing for other Lienholders r Dealership Filing as Lienholder

r Finance Company r Individual r Title Loan Company r Tower (No charge for online record access - Do not complete Section C)

r Other _________________________________________________________________________________________________________

Section D

Authorization

Signature of Individual, Partner, Business Owner, Corporate Officer, News Agent, or Government Agent Date (MM/DD/YYYY)

___ ___ /___ ___ /___ ___ ___ ___

Printed Name Title of Partner, Business Owner, Corporate Officer, News Agent, or Government Agent

I certify under penalty of perjury that the facts herein are true to the best of my knowledge. Any false afdavit is a crime under Section 575.050

of Missouri law.

Form

5017

Application for Online Account (Notice of Lien

Filing, Records Access, and Direct Debit)

Reset Form

Print Form

XYZ Business Check No. 4444

Hometown, USA

Pay to the Order of ___________________________________

121456789 8765432109812 4444

Example 1

Routing No. Dep. Acct. No. Ck. No.

XYZ Business Check No.

Hometown, USA

Pay to the Order of ___________________________________

R121456789 4444 8765432109812

Example 2

Routing No. Ck. No. Dep. Acct. No.

Form 5017 (Revised 02-2019)

To apply for an online account to file Notices of Lien 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 Section C when requesting online record access only.

Section A - Type

• Application Type - Select 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 - Select the appropriate box(es).

• Security Access Code - Must be provided when Online Record Access is selected. This code is issued by the Department of

Revenue to entities who requested and who qualify under the Driver’s Privacy Protection Act to obtain the personal information

contained in the Department’s vehicle and marine records. If you do not have a Security Access Code, you may apply by

completing a Request for Security Access Code (Form 4678). The application can be obtained by website: http://dor.mo.gov/forms/

Section B - Business and Contact Person

• Complete all blocks for both the business or individual and contact person information.

• Identification Number - Please record the FDIC number (bank), NCUA number (credit union), dealer number (licensed motor

vehicle or boat dealer), FEIN (any other type of business), or SSN (individual) as the identification number.

• Type of Business - Select 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 - Select 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.

• General Ledger letter from Financial Institution on letterhead must include the following information – Business Name, Account Type,

Routing Number, and Depositor (Business) Account Number. This original letter includes signature and title.

• Select appropriate box. Attach an original voided business or personal check or deposit slip or General Ledger letter to this application.

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 - Authorization

• All applications must include Signature, Printed Name, and Title.

• Submit the completed application to the address on the bottom of the first page.

• Approved titles to sign application are as follows:

Individual, Partners, Authorized Member, Corporate Officer, News Agent, or Government Agent

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 or financial institution. To redesignate, complete and submit a new

Application for Online Account (Notice of Lien Filing, Records Access, or Direct Debit) with the new information.