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.
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