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With this payment option you authorize the Oregon Department of Transportation’s Motor Carrier
Transportation Division (MCTD) to make ACH debits from your bank account for the amount and
on the date you specify.
By completing this authorization, you are entering into an agreement with MCTD under which
MCTD will make a payment option available through the Oregon Trucking Online program
whereby you may elect to make a single ACH debit from the bank account as listed below when
you select the ACH payment option available through the “Shopping cart” to pay for permits
through the Oregon Trucking Online program.
For purposes of this ACH Direct Payment Authorization Agreement, the terms “I” or “you” refer
to the person completing the electronic entries necessary to complete this authorization either
individually or on behalf of the corporate, partnership or other business entity listed below, as
applicable.
"I authorize MCTD to make a single ACH debit to the bank account as listed below" for the
purpose and as described below:
Payable To: ODOT/MCTD
Payment For: A Trucking Online transaction.
Payment Amount: The amount specified in a transaction.
Payment Date: Date of transaction.
Bank Account Nickname: CHASE EFROS
Bank Account Type: Business (or Corporate)
Bank Name: J.P. MORGAN CHASE
Bank Routing Number: XXXXX0013
Bank Account Number: XXXXX8722
Business Name: EFROS TRANSPORTATION
Business phone: (832) 900-9001
Trucking Online Email: efros.transportation@gmail.com
MCTD Account No: 160206
Authorized By: STEFAN EFROS
Title: PRESIDENT
This authorization agreement is to remain in full force and effect until:
a. The user withdraws from the Direct Payment program by deleting the assigned bank account
from the Trucking Online system.
b. MCTD revokes Direct Payment privileges due to miss use, NSF (Non Sufficient Funds) or
other reasons.
To withdraw from the Direct Payment program at any time follow these steps:
1. Log in to Trucking Online and select Manage Your Accounts from the main menu.
Transaction Rules:
I acknowledge that the origination of ACH transactions from my account must comply with the
provisions of U.S. and Oregon law and I agree to be bound by the rules of the Automated Clearing
House Network. I have provided the information above under penalty of perjury and represent
that it is true and correct as of the date given.
Security:
I represent and promise that in order to protect the security and integrity of the banking
information and access to the bank account I will not permit any unauthorized user to access the
information provided above in order to authorize a debit from the identified account. I am
responsible for protecting and for the use of all such user names and passwords.
If I believe that any of my user names or passwords have been stolen, or that someone has tried to
initiate a debit transaction under this authorization using one of my user names or passwords
without my permission, I will notify MCTD at once by calling 503-378-6699. Once a user name
and/or password is reported lost or stolen, MCTD will, block access to my debit transactions and
temporarily block access to the account until the matter is reviewed and resolved. A new password
will be issued to the Oregon Trucking Online authorized contact after resolution.
Record Retention:
I promise to maintain records of this authorization, the payments contemplated hereunder and the
person authorized to initiate such payments for a period of at least 3 years after each transaction. I
agree that I am responsible for the correctness of the information provided above and all
subsequent information provided under this authorization. I will promptly notify MCTD, in
compliance with Automated Clearing House Network rules and applicable law, of any erroneous
debits, credits or failures to debit or credit that appear on bank statements related to the above
identified account.
Governing Laws:
This Authorization is deemed entered into in the State of Oregon, and shall be governed and
construed in all respects by the laws of the State of Oregon, without giving effect to principles of
conflict of law.
Recorded Date & Time Stamp
06/30/2014 07:38:PM