555 W
right Way
Carson City, NV 89711
Reno/Carson City (775) 684-4368
Las Vegas area (702) 486-4368
dmv.nv.gov
ADM-205 (Revised 04/2022)
PAYMENT AUTHORIZATION FORM
DO NOT EMAIL FORM
Debi
t or Credit Card Number (One number per box)
- - -
Expiration Date
Car
dholder Information
Printed Name:
Payment Amount (Required):
Print your name as it appears on your card
Pursuant to NRS 353.1467, credit card payments of
$10,000 or more are not permitted and cannot be
split between multiple payments and/or card types
Cardholder Billing Address:
Street Address or P.O. Box City State Zip Code
License Plate # / Driver License # / Business License # / Records# / Motor Carrier #
of the transaction being processed:
Telephone:
Authorized Signature:
Date:
By signing this form, you give the DMV permission to debit your account for the payment amount on or after the
indicated date.
I authorize the DMV to charge the credit/debit card indicated in this authorization form according to the terms
outlined above. This payment authorization is for the amount indicated above only and is valid for one-time use
only. I certify that I am an authorized user of this credit/debit card and that I will not dispute the payment with
my credit/debit card company so long as the transaction corresponds to the terms indicated in the form.
Do not e-mail this authorization form. E-mailed forms will not be processed. E-mail is NOT a secure form of
transmittal to protect your card information.
Office Use Only
Super Tran ID:
Last four of card:
Technician Number:
Comments:
/
Month
Year
Payment Type: ☐ Master Card ☐ Visa ☐ Discover Card
