Louisiana Direct Deposit Form 2

OFS DD 2
Rev. 12/10
06/10 Issue Obsolete
Louisiana Department of Children and Family Services
Child Care Assistance Program
DIRECT DEPOSIT AUTHORIZATION FORM
Return to:
Provider Directory
P.O. Box 94065
Baton Rouge, LA 70804
Please TYPE or Legibly PRINT all information in INK.
Section 1:
PARTICIPANT CASE INFORMATION
Name:
Date of Birth:
Mailing Address:
City/State/ZIP:
Daytime Telephone #: (
)
Home Telephone #: (
Social Security Number:
)
Provider Number:
Section 2:
FINANCIAL INSTITUTION INFORMATION
Name of Financial Institution:
Mailing Address:
City/State/ZIP:
Telephone #:
(
)
Routing Number:
Account Type (Check One):
Check One:
New Request
Account Number:
Checking*
Savings*
Change Account
Cancel Direct Deposit
*Note: Be sure to include a voided check for checking accounts. For savings accounts, submit a statement from your financial
institution showing the account number and routing number.
Section 3:
AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT OF PAYMENTS
I authorize the Department of Children and Family Services (DCFS) to deposit my payments directly into
my checking account or savings account as specified above. DCFS is also authorized to adjust any
over/under deposit it has made to my checking account or savings account. I understand the
deposits/adjustments will be made electronically by Automated Clearing House Network (ACH)
transactions and I must allow the Federal Reserve two work days from the disbursement date to have the
funds available to my financial institution. I also understand the following: It is my responsibility to
provide correct routing and account information for ACH transmissions by attaching a voided check for a
checking account or a statement from my financial institution showing the account number and the
routing number for a savings account. The voided check must be imprinted with my name and address. If
my voided check does not include this information, a statement from my financial institution showing my
name, address, account number and routing number must be provided. I will immediately notify DCFS if
my banking information changes. I must submit a new Direct Deposit Authorization form to change or
cancel my direct deposit. I must notify DCFS of any changes to my address. I must include my name and
provider number on all correspondence regarding direct deposit. To verify when a payment is posted to
my account and funds are available, I will have to contact my financial institution.
By signing below I signify that I have read and agree to all of the conditions listed above.
Signature:
Date Signed:
Office Use Only
Date Entered:
Entered By:
DO NOT COMPLETE THIS FORM IF YOU WANT A STORED VALUE CARD
Direct Deposit Form Instructions
This form authorizes the Department of Children and Family Services to deposit payments directly into your
account. If you choose to have your child care payments sent to your financial institution, you must complete
this form to authorize this action. The financial institution may be any bank, savings and loan association, or
federal or state chartered credit union or similar institution. If you do not have an account in one of these
institutions contact the financial institution of your choice to establish an account.
Deposits will be made by an electronic funds transfer (EFT) from the Department of Children and Family
Services to your account, provided your financial institution is a member of the Automated Clearing House
(ACH) system. In the event your financial institution is not a member of the ACH System, a Stored Value
Card will be issued for Family Child Day Care Home and In-Home Providers only. Class A, Class M, and
School Child Care Providers must have Direct Deposit or they will not be eligible to receive payments
through DCFS.
Section 1-Provider Case Information
Name: Name of the provider. This is the name of the facility, In-Home provider, or Family Child Day Care
Home Provider. The name of the bank account must be in the name of the facility for Class A, Class M, and
School Child Care Providers. A personal account for these facilities is not acceptable.
Date of Birth: Enter the date of birth of the Family Child Day Care Home or In-Home Provider.
Mailing Address: The complete mailing address of the provider, including an apartment number (where
appropriate). This address must be kept current with the Provider Directory.
You must notify the Provider Directory when your address changes.
Telephone Numbers: Area code and daytime telephone number of the provider.
Social Security Number: Social Security number of the In-Home or Family Child Day Care Home provider.
The Social Security number is used to identify the provider’s records and payments.
Section 2-Financial Institution Information
Name of Financial Institution: Complete the name, address and telephone number of the financial
institution to which the payment will be sent (bank, savings and loan association, credit union, etc.) and the
branch designation.
Routing Number: The routing number is the bank’s federal identification number.
Account Number: The account number is a group of numbers assigned to an individual at a particular
financial institution for tracking purposes.
Account Type: Identify the type of account in which the payments are to be deposited. The account may
be either a checking or savings account. Attach a voided personal check for a checking account or a
statement from your financial institution showing the account number and routing number for a savings
account.
Reason for Completing this Form: Indicate if this is a new request, if you would like to make a change in
account information, or if you would like to cancel direct deposit.
Section 3- Authorization Agreement for Direct Deposit
Signature: Sign and date the form. The signature must be that of the provider.