Ohio > Statewide > Bureau Of Motor Vehicles > Miscellaneous
Request For Service by County Agency BMV 0399 - Ohio
| Request For Service by County Agency Form. This is a Ohio form and can be used in Miscellaneous Bureau Of Motor Vehicles Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
OHIO BUREAU OF MOTOR VEHICLES REQUEST FOR SERVICE BY COUNTY AGENCY State and County agencies must complete this form and submit it to the BMV when requesting to make payment for service by way of County Agency Voucher or Intra State Agency Voucher (ISTV). Attach a copy of the voucher, if applicable. A revenue transfer must be completed for the amount of service authorized through an ISTV or by way of check within 30 days after the service was provided. SERVICE REQUESTED DATE OF REQUEST: EXPLAIN TYPE OF SERVICE REQUESTED AMOUNT OF VOUCHER/ISTV (REQUIRED) $ BMV CASE # (IF REQUIRED) OTHER INFORMATION: CUSTOMER/RECIPIENT INFORMATION FIRST NAME STREET ADDRESS CITY STATE ZIP LAST NAME SOCIAL SECURITY # PHONE # MIDDLE INITIAL ( ) AGENCY INFORMATION AGENCY NAME STREET ADDRESS CITY AGENCY AUTHORIZED SIGNATURE STATE ZIP AGENCY CONTACT/CASE WORKER PHONE NUMBER ( ( ) ) FAX NUMBER E-MAIL ADDRESS X DO NOT WRITE BELOW THIS LINE KEY NUMBER (I.E. APP/DL NUMBER) SERVICE DATE SERVICE PROVIDED BY AMOUNT OF VOUCHER/ISTV PAYMENT/ISTV REC'D DATE PAYMENT PROCESSED BY $ NOTES: Mail to: Ohio Bureau of Motor Vehicles Revenue Management, P.O. Box 16521, Columbus, Ohio 43216-6521 PLEASE DUPLICATE THIS FORM AS NEEDED BMV 0399 11/04 American LegalNet, Inc. www.FormsWorkflow.com
|
|||||||
