DIRECT DEPOSIT APPLICATION
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)
() -
SECTION B - FINANCIAL INSTITUTION INFORMATION
FINANCIAL INSTITUTION NAME *
TELEPHONE # (Incl. Area Code)
() -
ADDRESS (PO Box or Street Address)


CITY
STATE/PROVINCE
  ZIP
  - 		COUNTRY
ROUTING NUMBER *    
RETYPE ROUTING NUMBER *    
ACCOUNT NUMBER *    
RETYPE ACCOUNT NUMBER *    
TYPE OF ACCOUNT *
 
SECTION C - DIRECT DEPOSIT AUTHORIZATION
Under Federal regulations in 45 CFR 302.38, payments cannot be disbursed to a private collection agency. Check this box to acknowledge you are authorized to receive support payments.
I understand this form authorizes the Ohio CSPC to initiate credits and correcting debits to the above account. A debit (withdrawal) to this account will only occur if a credit (deposit) is originated in error. I will receive notification if a debit to my account occurs.
I understand that any request for changes to this authorization must be received at least three (3) business days before the next payment is scheduled to be disbursed to my bank account.
I understand that the availability of funds is dependent on the posting schedule of my bank and it is my responsibility to verify availability.
I understand this agreement will remain in effect until the Ohio CSPC receives a written notice of cancellation from me or my financial institution, or until I submit a new direct deposit form to the Ohio CSPC.

   
* Required Fields. Blank Mail-In Form
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