Direct Deposit Authorization Form

DD 2
Rev. 07/15
Louisiana Department of Education
Child Care Assistance Program
DIRECT DEPOSIT AUTHORIZATION FORM
Return to:
CCAP Provider Certification
P.O. Box 2510
Baton Rouge, LA 70821
FAX: (225) 342-4180
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 Education (LDE) to deposit my payments directly into my checking account or
savings account as specified above. LDE 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 LDE if my banking
information changes. I must submit a new Direct Deposit Authorization form to change or cancel my direct
deposit. I must notify LDE 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:
Direct Deposit Form Instructions
This form authorizes the Department of Education (LDE) to deposit payments directly into your
account. 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.
All CCAP providers are required to receive CCAP payments through direct deposit. Deposits will be made by
an electronic funds transfer (EFT) from the Department of Education to your account, provided your financial
institution is a member of the Automated Clearing House (ACH) system.
Section 1-Provider Case Information
Name: Name of the provider. This is the name of the facility, In-Home provider, or Family Child Care
Provider. The name of the bank account must be in the name of the facility for Type III, Military, and
School Child Care Center Providers. A personal account for these facilities is not acceptable.
Date of Birth: Enter the date of birth of the Family Child Care 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 LDE.
You must notify the LDE 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 Care 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 or if you would like to make a
change in account information.
Section 3- Authorization Agreement for Direct Deposit
Signature: Sign and date the form. The signature must be that of the provider.