smiONE™ DEBIT CARD APPLICATION
smiONE Card
The Platinum smiONE Visa Prepaid Card is issued by The Bancorp Bank pursuant to a license from Visa U.S.A. Inc. The Bancorp Bank; Member FDIC. Card may be used everywhere Visa debit cards are accepted.
SECTION A - PAYEE INFORMATION
New     Change Request
NAME
First *
Middle
Last *
ADDRESS (PO Box or Street Address) *


Apt. No.
CITY *
STATE/PROVINCE *
  ZIP *
  - 		COUNTRY *
Case #
This number is 10 digits in length and begins with a 7. You can locate this number on documentation from your county child support agency.
* By entering one case number, all of your cases will be enrolled.
 
SOC SEC # * (No Dashes)
TELEPHONE # (Incl. Area Code)
() -
DATE OF BIRTH *
/ /
SECTION B - DEBIT CARD AUTHORIZATION
By clicking the Submit button, I authorize the Ohio CSPC to share information with SMI Card Services, LLC (smiONE™) for the purpose of establishing a Platinum smiONE™ Visa® Prepaid Debit Card account for me and to deposit my child support payments to my card account. This authorization cancels and replaces any direct deposit agreement I currently have in place with the CSPC. Upon authorization of my account with SMI Card Services, LLC, I agree to be bound by the Cardholder Agreement that I will receive with my card. This authorization will remain in effect until cancelled by me in writing to smiONE Card Services.

   
* Required Fields. Blank Mail-In Form
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