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Direct Payment Authorization Agreement

Submitted Successfully 06/30/2014  07:38:PM Pacific 


For status, visit "Direct Payment Account Maintenance"

IMPORTANT: For security this document will only display once.


Print this copy for your records.

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.

2. Select “Set Up & Manage Direct Payments”.

3. Select “Direct Payment Account Maintenance” .

4. Using the “Delete Account” function, click on the “Delete” Link.

Bank Account Changes:


If the bank account from which payments to MCTD is changed, I understand and agree that I
must complete a new authorization with the new bank account number correctly identified. Such
change in bank account number will constitute a new authorization for the new bank account. I
will print out and retain a record of any change to the bank account number and the new
authorization.

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.

Authorizing Direct Payment:


By completing the information above and the computer entries necessary to initiate the debit
transaction provided for by this process, I represent and warrant individually and, if applicable, on
behalf of the business entity listed above, that I have the necessary and full corporate or other
rights, power, authority and capabilities to provide this authorization and bind myself or the
business listed above to perform the obligations hereunder, and that such performance will not
violate the rights of any third party, nor any applicable federal, state or local law or regulation.

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.

Direct Payment Bank Returns and Fees:


In the event that your direct payment (ACH debit) is returned to MCTD due to Insufficient (NSF)
or Uncollected funds MCTD will attempt a second submission to your bank. You may be liable
for bank-side service charges or fees. If the second submission to the bank is unsuccessful due to
insufficient (NSF) or uncollectible funds, you may be liable for additional (bank-side) service
charges or fees. In addition to possible bank side fees, MCTD will immediately revoke your direct
payment (ACH) submission privileges pending review and attempt to contact you directly. MCTD
may assess a $25.00 service charge to your MCTD account and place your account on CASH
ONLY or CERTIFIED CHECK status for a period 6 months. When on CASH ONLY or
CERTIFIED CHECK status, the “Direct Payment” ACH option accessed through Oregon
Trucking Online will not be available. Any payments or transactions attempted through the
Oregon Trucking Online program must be paid with Visa or MasterCard only. Any payments or
transactions attempted over the phone must be paid with Visa, MasterCard, or guaranteed check.
All payments sent to MCTD through the US Mail must be paid with a CERTIFIED CHECK only.
Payments made directly to a MCTD office counter may be paid using VISA, MasterCard, CASH
or CERTIFIED CHECK only.

Representation and Responsibilities:


I represent to MCTD and the State of Oregon that I am not relying upon any advice, counsel, or
representations of MCTD or the State in providing this authorization and that I have consulted
with legal, regulatory, business, financial and accounting advisors to the extent I deemed
necessary, if at all, and have made my own decision to provide this authorization based upon my
own judgment, and not upon any view expressed by MCTD or the State. I understand the terms,
conditions, and risks of providing this authorization.

Policies & Liabilities:


To the extent allowed by applicable law, MCTD and the State will not be liable for any direct,
punitive, incidental or consequential damages: (i) In any action arising from or related to this
authorization or use of the Automatic Payment service, whether based in contract, tort (including
negligence), intended conduct or otherwise, including without limitation, damages relating to the
loss of profits, income or goodwill, regardless of whether you have been advised of the possibility
of such damages,(ii) for any Internet or telecommunications failure, computer virus, third party
interference, or MCTD, State or other third party software or hardware that may interrupt or delay
payments or access to the service or any Internet site or cause other problems or losses
(collectively, a “network failure”), and (iii) arising from third party unauthorized access to the
Automatic Payment services or for any failure to fulfill their obligations hereunder that results
from an act of God, war, civil disturbance, court order, legislative or regulatory actions,
catastrophic weather condition, earthquake, failure or fluctuation in electrical power or other
utility services, network failure or other cause beyond its reasonable control.

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 

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