Direct Deposit Enrollment Form

Direct Deposit Enrollment Form
Cuyahoga DD Family Supports Program

Please provide the information requested. Any incomplete or partially completed forms cannot be processed and may delay payment. If you have questions, please call NEON at 1-800-237-6828.

All accounts MUST be personal accounts in the provider’s name. We are not able to make payments to business accounts or accounts associated with the individual receiving respite services.

Please choose 1:*

I am a NEW Family-Selected Respite ProviderI am an EXISTING Family-Selected Respite Provider and wish to update my banking informationI am an Independent Certified Respite ProviderNone of the above

I want my Family Supports respite/other payments deposited into ONE of the following accounts:*

Checking - You will be asked to upload or take a picture of a voided check or direct deposit enrollment form COMPLETED BY your bankSavingsPre-paid credit or debit card - Please note: Routing and account numbers are NOT located on pre-paid credit or debit cards. You will need to call the customer service number on the back of your card to obtain the routing and account numbers.

Please upload or take a picture of a voided check OR direct deposit enrollment form COMPLETED BY your bank (Required if utilizing a Checking Account). To take a picture you must currently be completing this form on a device capable of taking pictures:*

Provider Name:*

First NameLast Name

Name of Individual you provide Respite care services for (if multiple, list only one). Please put n/a if not applicable:*

First NameLast Name

Name of Bank*

Routing Number*

MUST be 9 digits

Account Number*

Provider Mailing Address*

Street Address (Include Apt #, Up/Down, PO box if applicable)

Street Address Line 2

CityState

Zip Code

Provider Phone Number*

Please enter a valid phone number.

Provider Email*

example@example.com

Social Security Number*

I hereby authorize NEON to initiate credit entries to my account indicated above and PNC Bank to credit the same to such account.

Provider Signature*

Date*

Date