Pennsylvania Direct Deposit Form 2

PA SCDU Direct Deposit Enrollment Form
The payee/check recipient must fill in all the requested information in Section 1.
The bank/financial institution must complete Section 2
The payee/check recipient must advise PA SCDU in writing of any account changes in order to
remain enrolled in direct deposit.
The payee/check recipient’s name, address and Social Security number must match the
information on file in the PA Child Support Enforcement System, PACSES.
The account where the money is to be deposited must belong to the payee/check recipient of the
support order.
Mail the completed form to: PA SCDU, PO Box 61216, Harrisburg, PA 17106-1216
Attn: Exceptions Processing Department
When PA SCDU receives your direct deposit form and it has been correctly completed, direct
deposit will begin in approximately 10 business days.
New Enrollment
Account Change
Cancel Direct Deposit
Section 1 (to be completed by payee)
Please Print
Name of Payee/Check Recipient
Type of Depositor Account – check one
Street Address
O Checking
O Savings
Depositor checking or savings account number
City
State
Zip Code
(daytime) Area Code and Telephone Number
PACSES 10 digit member ID number
Payee/Joint Payee Certification
I certify that I am entitled to the payment identified
above and that I have read and understood the above
directions to complete this form. In signing this form,
I authorize my payments to be sent to the financial
institution named below to be deposited to the account
designated on this form.
Social Security Number
Signature
Date
Section 2 (to be completed by Bank/Financial Institution)
Name of Bank/Financial Institution
Routing number
Account Number
Name of Bank Representative
Signature of Bank Representative
Telephone number/ Date
All incomplete or incorrect enrollment forms will be returned to the sender for correction or additions.
1/20/05