The Ohio BMV 0399 form is a request document used by state and county agencies to seek payment for services provided. When an agency needs to make a payment through a County Agency Voucher or Intra State Agency Voucher (ISTV), they must complete this form and submit it to the Bureau of Motor Vehicles (BMV). It ensures that all necessary information is collected and processed efficiently.
The Ohio BMV 0399 form serves as a crucial tool for state and county agencies seeking reimbursement for services rendered. When agencies wish to make payments through a County Agency Voucher or an Intra State Agency Voucher (ISTV), they must complete this form and submit it to the Bureau of Motor Vehicles (BMV). The form requires essential information, including the date of request, type of service requested, and the amount of the voucher or ISTV. Additionally, agencies must provide customer or recipient details, such as name, address, and social security number. The form also necessitates the agency’s information, including contact details and an authorized signature. It is important to attach a copy of the voucher if applicable. After the service is provided, a revenue transfer must be completed within 30 days to ensure proper payment processing. The BMV 0399 form is not just a request; it is a structured approach to facilitate financial transactions between agencies and the BMV, ensuring accountability and efficiency in service delivery.
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
LAST NAME
MIDDLE INITIAL
STREET ADDRESS
SOCIAL SECURITY #
CITY
STATE
ZIP
PHONE #
(
)
AGENCY INFORMATION
AGENCY NAME
AGENCY CONTACT/CASE WORKER
PHONE NUMBER
FAX NUMBER
AGENCY AUTHORIZED SIGNATURE
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
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