DIRECT DEPOSIT AUTHORIZATION FORM VOID

DIRECT DEPOSIT AUTHORIZATION FORM
Michigan State Disbursement Unit
Michigan Department of Health and Human Services
New
Change
Cancel
(Check one box above and complete the entire form.)
Your Name (Please Print):
Last
First
Middle
Phone Numbers:
Home Phone
Work Phone
Other Phone
Current / New Address:
Number/Street/Apt Number
City
State/Zip
Social Security Number:
Country (if not US)
Case ID or Court Case (Docket) Number:
(Identify one case number, but multiple cases may be paid in a
single deposit.)
Number
County
Bank Name:
Bank Routing Number:
Bank Account Number:
Checking
Savings
For a CHECKING account:
Write VOID on an unused
check and attach here
1234
John and Mary Jones
123 Main Street
Anytown, MI 48888
Pay to:
For a SAVINGS account:
Contact your bank and
obtain written verification
of your account and
routing numbers. Attach
that verification to this
form.
$
VOID
DOLLARS
Anytown Bank
Anytown, MI 48888
For:
Do Not Complete Shaded Area
|: 072412345 |: 0012300456 ” ’ 1234
Routing Number
(9 digits)
Account Number
(up to 17 digits)
I authorize the State of Michigan to deposit all support payments into the designated financial institution and account, and to initiate correcting entries, if
necessary. I understand that the deposits will be made electronically, under the rules of the National Automated Clearing House Association (NACHA),
and the State of Michigan. This authorization will remain in effect until cancelled by me with written notification to the state, or cancelled by the financial
institution or the State of Michigan, at which time they will notify me by mail at the most current address they have on file for me.
Sign Here:
Date:
Mail this Form to:
MiSDU
Attn: Address Change
PO Box 30354
Lansing, MI 48909 – 7854
FAX: 517-318-4697
Michigan Department of Health and Human Services (MDHHS) will not discriminate against any individual or group because of race, religion, age, national origin,
color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing,
hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to an MDHHS office in your area.
DHS-1377 (Rev. 5-15) Previous edition obsolete. MS Word