Indiana Direct Deposit Form 1

DIRECT DEPOSIT AUTHORIZATION
P.O. Box 6098
Indianapolis, IN 46206-6098
Phone: 317-233-5437 or 1-800-840-8757
Fax: 317-241-9635
New Request
Change Request
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)
Daytime telephone number
City
State
ZIP code
City
State
ZIP code
Name of your financial institution (bank, credit union, etc.)
Address of your financial institution (number and street)
Telephone number of your financial institution
(
)
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 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 of custodial party
Date (month, day, year)
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 contacting the INSCCU at the number above or the Clerk of Court where
your order resides with any address changes.
* 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.
INSCCU
Direct Deposit Authorization
12/10/07