Direct Deposit Enrollment Form

ChildCareGroup (CCG) Food and Nutrition Program
Direct Deposit Enrollment Form
Please complete this form and attach a voided check. Submit this form to Angela Young, Food Program
Manager, ChildCareGroup, 1420 W. Mockingbird Lane, Suite 300, Dallas, TX, 75247; fax to Angela’s
attention at (214) 631-1943 or scan and email to [email protected]
Last Name
First Name
MI
Phone
Please Check Action
New
Change
Effective Date
Cancel
Month
Day
Year
Name of Financial Institution
A
C
C
O
U
N
T
Account Number (include hyphens but omit spaces and special symbols.)
Type of
Account
Checking
Savings
Routing Number
Ownership of Account
Self
Joint
Other
I hereby authorize CCG to deposit any amounts owed me by initiating credit entries to my account at the financial
institution (hereinafter“Bank”) indicated on this form. Further, I authorize Bank to accept and to credit any credit
entries indicated by CCG to my account. In the event that CCG deposits funds erroneously into my account, I
authorize CCG to debit my account for an amount not to exceed the original amount of the erroneous credit. This
authorization is to remain in full force and effect until CCG and Bank have received written notice from me of its
termination in such time and in such manner as to afford CCG and Bank reasonable opportunity to act on it.
Signature ______________________________________ Date____________
NOTE: ATTACH A VOIDED CHECK HERE
Updated 5/21/2013
Instructions for Processing Direct Deposit Authorization
The information you are requested to provide on this form is confidential and is needed to process your Direct
Deposit request. The information will be used to process reimbursement data from ChildCareGroup Food and
Nutrition Program to the financial institution and/or its agent.
1. Provider Information (always complete this section)
2. Financial Institution Name (the name of the institution to which payments are to be directed)
3. Account Number (your account number at your financial institution)
4. Type of Account (put an “X” in the appropriate space to indicate a checking or savings account)
5. Routing Number (your financial institutions 9-digit routing transit number)
6. Ownership of Account (put an “X” in the appropriate space to indicate self, joint or other)
7. Authorization Sign and date the request form after you have carefully read the instructions and Privacy Act
Statement
Terms and Conditions for Participating in Direct Deposit
When you participate in Direct Deposit, you have the convenience of having your authorized reimbursements
deposited directly into your account at your financial institution. Direct Deposit is required for all participants in
ChildCareGroup Food and Nutrition Program.
1.
Your financial institution must be a member of an Automated Clearing House in order for you to participate in Direct
Deposit.
2.
If an electronic transfer is returned to CCG, or for any reason cannot be made to your account, CCG will investigate the
cause and after the funds are located, will either re-issue the credit to another account or issue a “live” check to you.
It is your responsibility to notify ChildCareGroup Food Program immediately of any changes in your account, such as
account closure or change in account number. Complete this form and indicate the action is a CHANGE, and specify the
new account information.
Your financial institution or CCG may cancel Direct Deposit. CCG reserves the right to automatically cancel your
participation in the Direct Deposit program upon termination of participation in the food program. CCG assumes no
responsibility for any bank charges incurred as a result of temporarily or permanently discontinuing Direct Deposit.
3.
4.
If you have questions regarding this form, Direct Deposit or any electronic transfers to
your account, contact Angela Young at (214) 905-2464 or [email protected]
Updated 5/21/2013