Fillable Printable Child Support Automatic Withdrawal Authorization Form - Missouri
Fillable Printable Child Support Automatic Withdrawal Authorization Form - Missouri
Child Support Automatic Withdrawal Authorization Form - Missouri
STAT E OF MISSOURI
FAMILY SUPPORT PAYMENT CENTER
AUTOMATIC WITHDRAWAL AUTHORIZATIO N
INSTRUCTIONS
Child and/or spousal support payments that you pay to the Family Support Payment Center (FSPC) may be
automatically withdrawn f r om your bank account and paid t o t he FSPC. Car efully read the enclosed Frequently
Asked Questions About Automatic Withdrawalto learn more about this payment method before completing
this authorization. If you want your support payments automatically withdrawn from your bank account and
paid to the FSPC, complete the Automatic Withdrawal Authorizationusing the following instructions. If you
want support payments withdrawn f or more than one support order, you must complete a separate Automatic
Withdr awal Authorizationfor each order .
With t he exception of your sig natur e, type or pr int the r equest ed inf ormat ion. Retur n t he orig inal application to:
FAMILY SUPPORT PAYMENT CENTER, PO BOX 109006, JEFFERSON CITY, MO 65110–9006. Keep a
copy of the application and these instructions for your records.If you do not provide all the information
requested, the FSPC may not be able to process your authorization. If you need help completing the
Automatic Withdrawal Authorization, contact the FSPC between 8:00 a.m. and 5:00 p.m., Monday through
Friday at 1–888–761–3665. You may also write to the FSPC at the above address.
ORIGINAL OR CHANGED AUTHORIZATION
In the top r ight–hand corner of the form, c heckonebox to indicate whether this aut hor ization is:
•An original automatic withdrawal authorization (you do not currently make support payments to the FSPC
by automatic withdrawal but are completing t his aut hor ization to do s o) ; or
•A request to change your existing automatic withdrawal authorization (you currently make support
payments to t he FSPC by autom atic withdrawal but want to change the payment f r eq uency, payment date,
payment amount, financial institut ion, and/ or ac count from which your payments are withdrawn).
SECTION A — PAYOR INFORMATION
1.Enter your name (if you are the person oblig at ed t o pay support ).
2.Enter your Social Security number.
3.Enter your home address .
4.Enter your e–mail a ddr es s if you wish to receive electronic payment confir m at ion not ices from t he FSPC.
5.Enter your telephone number , including t he area code. A daytime telephone number is pr eferred.
6.Enter your eight –dig it cas e num ber .
7.Enter your court or der number. If you want support payments withdrawn for more t han one support order ,
you must complete a separ at e Aut omatic Wit hdr aw al Aut hor izationfor each order.
8.Enter the count y in which your support order was entered.
SECTION B — FINANCIAL INSTITUTION INFORMATION
You mustattach a voided check or deposit slip to the authorization in the space indicated, or the
FSPC WILL NOT process your authorization.
1.Enter the com plet e nam e of the financial institution where you have your account.
2.Enter the financial institution’s telephone num ber , including t he area code.
3.Check the box that describes the type of acc ount from which you want support payments withdrawn.
4.Enter your financial institution’s nine–digit routing number. The routing number is printed on the bottom
left–hand portion of your checks and deposit slips ( see Examples 1 and 2 on reverse side) .
5.Enter your deposit or account number. If your account is a checking account, the account number is
printed on the bottom of your personal checks following your routing number. It may be the first series of
digits after the routing num ber (see Example 1 on reverse side), or it m ay be the ser ies of digits t hat follow
your check number (see Example 2 on reverse side). Do notinclude your check number in the account
number.
NOTE
:Enter only numbers for your routing and account numbers. Sometimes there are special symbols
before or after the routing and account numbers on your check. Those special symbols should not
be included.
MO 886–3953 (8–14) (OVER) CS–161(Rev. 8–14)
EXAMPLE 1
CATHY SMITH123
123 STREET
ANYTOWN, MO 65000DATE___________
PAY TO T HE ORDE R OF _______________________________|$_______________
______________________________________________________________DOLLARS
MEMO________________________________________________
12345678998765432111234123
EXAMPLE 2
CATHY SMITH123
123 STREET
ANYTOWN, MO 65000DATE___________
PAY TO T HE ORDE R OF _________________________________| $_______________
______________________________________________________________DOLLARS
MEMO________________________________________________
12345678912398765432111234
SECTION C — W ITHDRAWAL AMOUNT AND FREQUENCY
Check onebox in Section C to indicate how often you want support payments withdrawn from your bank
account. Enter the amount of each withdrawal and when withdrawals should occur.
SECTION D — I MPORTANT INFORMATION REGARDING WI THDRAWAL DATES
Carefully read the informat ion in Section D regarding withdrawal dates. If you do not want payments withdrawn
fr om your account as indicated in Sect ion D, do notcomplete the Aut om atic Withdr aw alAuthorization.
SECTION E — AUTOMATIC WITHDRAWAL AUTHORIZATION
Carefully read the information included in Section E and sign and date the form to agree to the terms of the
automatic withdrawal. If you do not agree to the terms of the automatic withdrawal, do not complete the
Automatic Withdrawal Authorization. For joint accounts, the joint account holder must also sign and date the
form.
WHAT YOU SHOULD E XPECT
•Your automat ic payment authorization will be processed when it is received at the FSPC.
•The FSPC will send a “pre note” or test of your automatic withdrawal to your bank to ensure routing and
account numbers ar e acc ur at e.
•You will begin having payments withdrawn from your account once the pre note is complete. This should
be approximately fivebusinessdays after the FSPC receives your application. The actual time will depend
on how often you request ed payment s be withdrawn fr om your account.
•During the time it takes to process the authorization and pre note the automatic withdrawal, you must
continue to make support payments by another m et hod.
•If your bank does not honor your withdrawal because of insufficient funds, a stop payment or a closed
account, the FSPC may term inate your autom atic withdrawal enrollment. Any resulting debt to t he FSPC is
subjectto collection action.
CHANGING OR TERMINATING YOUR AUTOMATIC WITHDRAWAL AUTHORIZATION
Support payments will continue to be withdrawn from your desig nated account at your f inancial institution until
you notify the FSPC that you wish to terminate the withdrawals or change the financial institution and/or
account f r om which your payments are withdrawn. To c hange t he payment f req uency, payment dat e, payment
amount, financial institution, and/or account from which your support payments are withdrawn, you must
complete a new Automatic Withdrawal Authorization. To terminate your automatic withdrawal authorization
and/or to obtain an additional Automatic Withdrawal Authorization, contact the FSPC at 1–888–761–3665. It
will take approximately 30 days to process yourtermination request and/or your new Automatic Withdrawal
Authorization.
Routing
Number
Routing
Number
Account
Number
Account
Number
Check
Number
Check
Number
MO 886–3953 (8–14)CS–161(Rev. 8–14)
STAT E OF MISSOURI
FAMILY SUPPORT PAYMENT CENTER
This is an original authorization
AUTOMATIC WITHDRAWAL AUTHORIZ ATION
This is a change to an existing authorization
SECTION A — PAYOR INFORMATION
NAME (LAST, FIRST, MIDDLE)
SOCIAL SECURITY NUMBER
ADDRESS (PO BOX OR STREET ADDRESS)(APT NUMBER)
(CITY)(STATE) (ZIP CODE)
E–MAIL ADDRESS (PROVIDE IF YOU WISH TO RECEI VE ELECTRONIC PAYMENT CONFIRMATION NOTICES)
TELEPHONE NUMBER (INCLUDING AREA CODE)
CASE NUM BER (EIGHT DIGITS)
COURT ORDER NUMBER
COUNTY OF ORDER
SECTION B — FINANCIAL INSTITUTION INFORMATION (VOIDED CHECK OR DEPOSIT SLIP MUST BE ATTACHED)
FINANCIAL INSTITUTION NAME
TELEPHONE NUMBER (INCLUDING AREA CODE)
STAPLE VOIDED
CHECK OR
DEPOSIT SLIP
HERE
TYPE OF ACCOUNT (CHECK ONE BOX)
CHECKING
SAVINGS
ROUTING NUMBER (9 DIGITS)
ACCOUNT NUMBER
SECTION C —WITHDRAWAL AMOUNT AND FREQUENCY(INDICATE ONE OF THE FOLLOWING OPTIONS)
WITHDRAW MY PAYMENT ONCE A MONTH
AMOUNT OF WITHDRAWALDATE OF WITHDRAWAL
WITHDRAW MY PAYMENT TWICE A MONTH
AMOUNT OF EACH WITHDRAWALDATES OF WITHDRAWAL
1ST2ND
WITHDRAW MY PAYMENT EVERY TW O WEEKS
AMOUNT OF EACH WITHDRAWAL
DAY OF WITHDRAWAL (FOR EXAMPLE, MONDAY)
WITHDRAW MY PAYMENT ONCE A WEEK
AMOUNT OF EACH WITHDRAWAL
DAY OF WITHDRAWAL (FOR EXAMPLE, MONDAY)
SECTION D – IMPORTANT INFORMATION REGARDING WITHDRAWAL DATES (PLEASE READ CAREFULLY)
•If a withdrawal date falls on a Saturday, Sunday or banking holiday, the Family Support Payment Center (FSPC) will
withdraw the payment on the following banking business day.
•If a withdrawal date f alls on the last day of the m onth and t hat day is a Saturday, Sunday or banking holiday, the FSPC will
deduct the payment on the last banking business day of the month.
•If a withdrawal date does not occur in each month (for example, the 31st), the FSPC will deduct the payment on the last
banking business day of the month during months in which that date does not occur.
•Twice–monthly withdrawals must be based on one of the following schedules: 1st
and 16th; 2nd and 17th; 3rd and 18th;
4th and 19th; 5th and 20th; 6th and 21st; 7th and 22nd; 8th and 23rd; 9th and 24th; 10th and 25th; 11th and 26th; 12th and
27th; 13th and 28th; 14th and 29th; or 15th and 30th.
•
The FSPC will apply the payment to your support order on the day it is withdraw n from your account.
SECTION E — AUTOMATIC WITHDRA WAL AUTHORIZATION
I hereby authorize the above withdrawals from my account for payment to the FSPC. I understand this authorization does
notexem pt me f rom any enforcem ent actions allowable under st ate and federal law. I understand the FSPC m ay terminate
my automatic withdrawal enrollment if my financial institution does not honor my withdrawal authorization because of
insufficient funds, a stop payment or a closed account. Any resulting debt to the FSPC is subject to collection action.
ACCOUNT HOLDER’S SIGNATURE
DATE SIGNED
SECOND ACCOUNTHOLDER’S SIGNATURE (REQUIRED FOR JOINT ACCOUNTS)
DATE SIGNED
SECTION F — FOR FSPC USE ONLY
MEMBER NUMBER
DATE AUTHORIZATION RECEIVED
DATE WITHDRAWALS WILL START
MO 886–3953 (8–14) CS–161 (Rev. 8–14)
MO 886–3954 (Rev. 8–05) (Over)CSE –161A (Rev. 8–05)
FREQUENTLY ASKED QUESTIONS ABOUT AUTOMATIC WITHDRAWAL
1. What is Automatic Withdrawal Authorization?
Automatic Withdrawal Authorization is your permission for the Family Support Payment Center (FSPC) to
withdraw child and/or spousal support from your checking or savings account by electronic funds transfer.
2. What are the benefits of automatic withdrawal?
Automatic withdrawal allows money to be electronically transferred from your bank account to the FSPC’s
bank account. Automatic withdrawal eliminates the possibility of lost payments and mail delays.
3. Can I pay all of my child and/or spousal support by automatic withdrawal?
Child and/or spousal support payments you pay to the FSPC may be paid by automatic withdrawal. If you
have more than one support order, you must complete a separate Automatic Withdrawal Authorization for
each support order.
4. How do I sign up for automatic withdrawal?
To sign up for automatic withdrawal, complete the enclosed Automatic Withdrawal Authorization.
Instructions are attached to the Automatic Withdrawal Authorization to assist you in completing this form.
Make sure you include the financial institution routing number, account number and a deposit slip or voided
check with your authorization.
5. How often can I have support payments withdrawn from my bank account?
You choose the dates on which the FSPC will withdraw your payments. You may have payments
withdrawn once a month, twice a month, every two weeks or once a week. You should choose a payment
frequency and dates that correspond with the frequency and dates required in your support order. Twice–
monthly withdrawals must be based on one of the following schedules:
1st and 16th 6th and 21st 11th and 26th
2nd and 17th 7th and 22nd 12th and 27th
3rd and 18th 8th and 23rd 13th and 28th
4th and 19th 9th and 24th 14th and 29th
5th and 20th 10th and 25th 15th and 30th
6. Will support payments ever be withdrawn from my account on a date other than a date I indicate on
the Automatic Withdrawal Authorization form?
Your support payments will be withdrawn on the date or dates you indicate unless one of the following
occurs:
•If the withdrawal date you indicate falls on a Saturday, Sunday or banking holiday, the FSPC will
withdraw the payment on the following banking business day.
•If the withdrawal date you indicate falls on the last day of the month and that day is a Saturday,
Sunday, or banking holiday, the FSPC will deduct the payment on the last banking business day of the
month.
•If the withdrawal date you indicate does not occur in each month (for example, the 31st), the FSPC will
deduct the payment on the last banking business day of the month during months in which that date
does not occur.
7. How can I verify that I have received credit for a payment once it has been withdrawn from my
account?
The FSPC will apply the payment to your support order on the day the withdrawal occurs.If you enter your
e–mail address on the Automatic Withdrawal Authorization form, the FSPC will send you an electronic
payment confirmation notice when the payment is credited. Otherwise, you can verify on the day following
the withdrawal date that the FSPC has credited your payment by calling the Payment Information Line at
1–800–225–0530. When making this call, you must enter your eight–digit case number to receive payment
information. If you do not know your eight–digit case number, contact the FSPC at 1–888–761–3665 to
obtain this number.
8. What if my bank does not honor my automatic withdrawal authorization?
If your bank does not honor your withdrawal authorization because of insufficient funds, a stop payment or
a closed account, the FSPC will terminate your automatic withdrawal enrollment. Any resulting debt to the
FSPC is subject to collection action. A debt to the FSPC results when the FSPC disburses a support
payment to the payee (the person to whom you owe support) based on your withdrawal authorization, and
your bank does not honor the withdrawal for one of the above reasons.
9. How do I stop or change the automatic withdrawal of my support payments?
To change the payment frequency, payment date, payment amount, financial institution and/or account
from which your support payments are withdrawn, you must complete a new Automatic Withdrawal
Authorization. To stop your automatic withdrawal and/or obtain an additional Automatic Withdrawal
Authorization, contact the FSPC at 1–888–761–3665. It will take approximately 30 days to process your
termination request and/or your new Automatic Withdrawal Authorization.
10. If I have my support payment withdrawn from my bank account, am I exempt from enforcement
actions such as income withholding (also known as wage withholding or garnishment)?
No, automatic withdrawal does not exempt you from any enforcement actions allowable under state and
federal law including, but not limited to, income withholding.
If you are already paying support through income withholding, the income withholding will not terminate
because you complete an Automatic Withdrawal Authorization. You should only complete an Automatic
Withdrawal Authorization if you want to pay more support than your employer is already withholding.
If the Family Support Division (FSD) issues an income withholding order for support you owe after you
have completed an Automatic Withdrawal Authorization, FSD cannot stop payments from being withdrawn
from your bank account. If you no longer want support payments automatically withdrawn from your bank
account, you must contact the FSPC at 1–888–761–3665 to request that your Automatic Withdrawal
Authorization be terminated.
