North Carolina Direct Deposit Form 3

North Carolina Child Support Enforcement Program
DIRECT DEPOSIT AUTHORIZATION
PLEASE COMPLETE IN BLUE OR BLACK INK. INCOMPLETE OR INCORRECT INFORMATION MAY RESULT
IN A DELAY IN PROCESSING THIS REQUEST. ALLOW 3 TO 4 WEEKS FOR DIRECT DEPOSIT TO TAKE EFFECT.
Until this request is processed, payments will be made by debit card or check.
NAME: __________________________________ _____________________________________ _____
(LAST)
(FIRST)
SOCIAL SECURITY NUMBER______________________________
(MI)
MPI #______________________
ADDRESS: __________________________________________
HOME PHONE # (____)__________
(STREET/POB)
________________________________________________________ WORK PHONE # (____)_________
(CITY)
(STATE)
(ZIP CODE)
1. CHECK THE TYPE OF REQUEST BELOW:
____ START/CHANGE DIRECT DEPOSIT – CHECK TYPE OF ACCOUNT AND PROVIDE DOCUMENTATION.
____ CHECKING ACCT – ATTACH A VOIDED PREPRINTED CHECK TO THIS FORM (NO STARTER CHECKS); OR
HAVE THE BANK COMPLETE THE INFORMATION IN #2 BELOW. READ AND SIGN #3 BELOW.
____ SAVINGS ACCT – THE BANK MUST COMPLETE #2 BELOW. READ AND SIGN #3 BELOW.
____ STOP DIRECT DEPOSIT – DO NOT ATTACH A CHECK. PLEASE SIGN # 3 BELOW.
2. BANK INFORMATION – THE BANK MUST COMPLETE THIS SECTION FOR A SAVINGS ACCOUNT OR IF YOU DO
NOT HAVE A PREPRINTED CHECK.
BANK NAME___________________________________________________ BANK PHONE # ____________________
BANK ADDRESS_________________________________________________________________________________
BANK ROUTING NUMBER ____ ____ ____ ____ ____ ____ ____ ____ ____
BANK ACCOUNT NUMBER ________________________________________
BANK REPRESENTATIVE’S NAME (PRINTED) ___________________________________________________________
BANK REPRESENTATIVE’S SIGNATURE_________________________________________ Date ___/____/_______
3. AUTHORIZATION AND SIGNATURE. PLEASE READ, SIGN AND DATE. PLEASE DO NOT SEND CORRESPONDENCE WITH THIS
DOCUMENT.
I hereby authorize the NC Child Support Enforcement program (CSE) to deposit my child support payments to the
financial institution account named above. CSE will make deposits to this bank account until I cancel the authorization
and CSE has time to process the cancellation. I authorize CSE to contact the financial institution and make debit entries
and adjustments for any credit entries made in error to my account. I understand that until this request is processed,
payments will be made by debit card or check.
YOUR SIGNATURE: __________________________________________
DATE:______/______/_______
MAIL SIGNED ORIGINAL COMPLETED FORM TO:
NCCSE –EFT
PO BOX 19807
Raleigh, North Carolina 27619
If you have questions or address changes, call 1-800-992-9457.
DSS-4718 Rev 08/2009
For Office Use Only: Date of Receipt____________________