Fillable ACH DEBIT AUTHORIZATION/AGREEMENT (Virginia Department of Motor Vehicles)

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ACH DEBIT AUTHORIZATION/AGREEMENT (Virginia Department of Motor Vehicles)

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FMS 310 (06/25/2015)
ACH DEBIT
AUTHORIZATION/AGREEMENT
SPECIAL NOTIFICATION
This form is for ACH DEBIT transactions only.
For information on ACH CREDIT transactions contact:
DMV Financial Management Services (FMAS)
(804) 367-1884
You may be asked to provide your Federal Employer Identification Number (FEIN) or DMV assigned account
number as proof of identification.
FMS 310 (06/25/2015)
ACH DEBIT
AUTHORIZATION/AGREEMENT
COMPANY CHECKING ACCOUNT
COMPANY SAVINGS ACCOUNT
DEBIT FUNDS FROM: (Check one)
IFTA (International Fuels
Tax Agreement)
ACCOUNT NUMBER
ACCOUNT NUMBER
FTX (Fuels Tax)
ACCOUNT NUMBER
HP (Hauling Permits)
ACCOUNT NUMBER
EZFLT
ACCOUNT NUMBER
WHX ( Fuels Wholesale Sales Tax)
ACCOUNT NUMBER
IRP (International
Registration Plan)
ACCOUNT NUMBER
DLR (Dealer Services)
COMPANY CERTIFICATION
AUTHORIZED COMPANY REPRESENTATIVE NAME (print)
AUTHORIZED COMPANY REPRESENTATIVE SIGNATURE
DATE (mm/dd/yyyy)
AUTHORIZED DMV REPRESENTATIVE NAME (print)
AUTHORIZED DMV REPRESENTATIVE SIGNATURE
DATE (mm/dd/yyyy)
TELEPHONE NUMBER
FEE PAYMENT TYPE TO DEBIT
Check only one fee payment type and enter account number - Complete a separate ACH Debit Authorization/Agreement
(FMS 310) for each additional Fee Payment type.
ACCOUNT NUMBER
LD (Liquidated Damages)
DMV ACCEPTANCE SIGNATURE
The Company identified above authorizes the Department of Motor Vehicles (DMV) to use the Automated Clearing House
(ACH) to debit funds from the specified company bank account for the fee payment type indicated.
The company understands that 6 business days are required for DMV's originating bank to verify the company's bank
account and initiate ACH pre-notification - during which time no ACH debits will be transmitted to the company's bank
account.
The company certifies that the specified bank account is open to ACH debit transactions and maintains sufficient funds for
the Fee Payment Type to be paid.
The company understands that if DMV receives 2 returned ACH Debits from the company's bank, it is DMV Policy to require
future payments to be made in certified funds.
This Authorization/Agreement becomes effective immediately upon signature by both parties. It remains in force until written
notification by either party is submitted 30 days prior to termination. If both parties agree in writing, this agreement may be
terminated in less than 30 days.
Purpose A company uses this form to authorize the Department of Motor Vehicles (DMV) to use the Automated
Clearing House (ACH) for debit transactions from the company's bank account.
Instructions Complete this form for Debit payments only. Send completed form to DMV Cashier's Office at the above
address.
COMPANY NAME
COMPANY FEIN
COMPANY ADDRESS
STATE
ZIP CODE
COMPANY ACCOUNT ROUTING NUMBER
COMPANY ACCOUNT NUMBER
COMPANY BANK NAME
COMPANY INFORMATION
ACCOUNT NUMBER
ARB (On-line Billing)
( )
FMS 310 (06/25/2015)
ACH DEBIT AUTHORIZATION INFORMATION
Automated Clearing House (ACH) debit transactions electronically transfers funds from the company's bank account to
DMV on a next day basis which can assure timely payments and cash management. Use ACH Debit transactions to pay
taxes/fees due DMV.
Complete a separate ACH Debit Authorization/Agreement (FMS 310) for each type of fee payment to be made by debit
to DMV.
DMV (through its bank) will initiate ACH pre-notifications to verify the company's bank transit/routing number & account
number.
All bank information submitted to DMV is kept in a secure database for the company's protection and accessed only for the
purpose of paying fees/penalties to DMV.
Verification takes 6 business days. No live ACH debits can be transmitted to the company account(s) and no transaction
using ACH Debit can be completed during the verification process.
In the event the company has an ACH Debit block feature on its bank account the company must arrange with its bank to
allow ACH Debits presented by DMV.
At the end of the 6 day verification process, the company can request DMV to debit the company's account.
If necessary, DMV will present a debit transaction to the company's bank twice. If the debit transaction is unsuccessful
after being presented twice, DMV notifies the company to make alternate payment arrangements.
If DMV receives 2 returned ACH Debits from the company's bank, it is DMV policy to require future payments to be made in
certified funds.
The company should retain a copy of the DMV transaction for company monthly reconciliation.
ACH rules require that the company's bank provide a notice to the company - within 2 banking days - of a debit transaction
from the company account. If the company's bank is unable to meet this requirement - the company should instruct the
bank to contact the regional ACH Association (EastPay, Inc. in Virginia) for assistance in interpreting and printing this
notice information.
The company may modify bank account information in writing 14 days in advance of any transaction to be made on the
account.
Inactive accounts will be deleted from DMV's database after 3 years.
For questions about the ACH Debit process for DMV Fee payments contact the DMV Financial Service Administration at
804-367-1884, or email Deborah.Bradby@dmv.virginia.gov.
ACH DEBIT CONTACT
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ACH DEBIT AUTHORIZATIONAGREEMENT (Virginia Department of Motor Vehicles)

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Completed 2 November 2020

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