Free Utah Recurring Credit Card Charge Authorization, TC-894 - Utah

Recurring Credit Card Charge Authorization
Company name Card holder's name

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Dealer number Card holder's telephone number Card holder's email address State ZIP code

TC-894 Rev. 5/04

Billing address City Card type (Check one) Visa Card number MasterCard Discover American Express

DMV accounts receivable number

Expiration date (mo./yr.)

Date this authorization expires This authorization will expire on the expiration date for this credit card, unless you want to terminate this authorization sooner. If you want to terminate this authorization sooner, provide a date for expiration.

I authorize the Division of Motor Vehicles to automatically charge my credit card account, shown above, for the legal payable amount allowed for services provided. I understand that any payments are based on the current legal price information available, during the registration process. My right to use this service is subject to any limits established by my credit card issuer. It is my responsibility to update the credit card information that is used to pay for this service. I understand that I may notify the Division of Motor Vehicles by written request at anytime to terminate this authorization. The Division of Motor Vehicles reserves the right to charge this account without requiring the customer's signed authorization for each transaction. Also, the Division of Motor Vehicles reserves the right to terminate this authorization agreement at anytime.
Card holder's signature (read statement above) Today's date

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