DIRECT DEPOSIT AUTHORIZATION

* This authorization requests the disclosure of your Social Security number in accordance with IC 4-1-8-1. Disclosure is mandatory; this record cannot be processed without it.

New requestChange request

P.O. Box 6098 Indianapolis, IN 46206-6098 Telephone: 317-233-5437 Toll-free: 1-800-840-8757 Fax: 317-241-9635

Please complete this form and mail it to the address above if you wish to have your support payments deposited automatically into your checking or savings account. You may choose only one account to which these funds will be deposited, regardless of the number of child support cases that you have open in the State of Indiana. No separate notice of deposit will be sent to you when funds are disbursed. Please keep a copy of this form in your records. If you change accounts, you must complete a new authorization form.

Name of custodial party

Social Security Number of custodial party

Home address (number and street)

City

State

Zip Code

Daytime Phone Number

Area CodePhone Number

Name of your financial institution bank, credit union, etc

Address of your financial institution (number and street)

City of your financial institution

State of your financial institution

Zip Code of your financial institution

Phone Number of your financial institution

Area CodePhone Number

Routing number of your financial institution

You may have your payments deposited to one of the following:

Checking account number

Savings account number

FOR CHECKING ACCOUNT: You must include a voided check (with your name and account number machine encoded – we cannot accept “starter” checks that do not have a machine printed name and address If your account is debit card only and you do not have checks, you must include a copy of the portion of your monthly account statement that shows your name and account number.

FOR SAVINGS ACCOUNT: You must include a savings account deposit slip (with your name and account number machine encoded If your deposit slip does not have this information, you must include a copy of the portion of your monthly account statement that shows your name and account number. If your deposit slip has a number that starts with a 5, that is not the routing number. You will need to send the portion of your monthly statement with the Bank Routing number and your account number.

Deposits will not begin for at least ten (10) business days after this authorization form is received at the INSCCU in order to verify information with your financial institution. Each deposit will be available in your bank approximately two (2)

business days from the posting date.

This authorization applies to funds received at the INSCCU and the Clerk of Courts that are using Electronic Banking to disburse funds. It does not apply to funds received in Clerk of Courts offices that are not using Electronic Banking.

I authorize the Indiana State Child Support Bureau to initiate debit entries and adjustments for any credit entries in error to my account, and I authorize the bank to perform those transactions.

Signature

Date (month, day, year)

Date

If funds are returned by the Financial Institution for any reason (e.g., you have closed your account), Direct Deposit will be terminated and these funds will be issued by check to your address on the Child Support System. It is your responsibility to maintain a valid address in the Child Support System by calling the phone number listed above or by contacting the Clerk of Court where your order resides.