Fillable Printable Direct Deposit Authorization Agreement Form - Illinois
Fillable Printable Direct Deposit Authorization Agreement Form - Illinois
Direct Deposit Authorization Agreement Form - Illinois
ILLINOIS
STATE DISB URSE MENT UNIT
P.O. Box 5921
Car ol Stream, IL 60197-5921
Custom er Ser vice: (877) 225-7077
DIRECT DEPOSIT AUTHORIZATION AGREEMENT
I, hereby authorize the Illinois State Disbursement Unit, (SDU) to initiate credit entries for deposit of
child support
payments and if necessary, to initiate debit entries and adjustments for any credit
entries made in error to my account
at the Depository Institution named below.
Account Type (check one)
Chec ki ng A c c ount
Savings Account (
Contact you r bank to obtain t he bank routing number and savings ac count number)
Name and Lo cation of Bank
_____________
Name of bank City State Zip
Bank Rout ing Number
9-digit routing number
B ank Acc ount Number
This authorization is to remain in full force and effect until the SDU has received written notification from me of its
termination in such time an d in such m anner as to afford the SDU and the Bank a rea sonabl e oppor t uni t y to act on it.
Full Name:
Daytime Phone Number:
List all the docket numbers to which direct deposit authorization agreement will apply:
Docket Number Issuing County
Signature (required to validate this request) Date
Please fax the completed form with the above referenced information to (630) 221-2312 or mail to the Illinois State Disbur sement
Unit at the above address. The process to establish this service requires approximately 2-4 weeks. In the interim, checks will
continue to be mailed to your address.
To receive notification on the status of your direct deposit application via a text message or an email from the State
Disbursement Unit please provide the requested information below with your preferred method of notification.
Mobile phone number: _________________________________ Email: ____________________________________________________
(Standard Text Messaging rates may apply) (Please print and write clearly)
Preference (Circle One): Text Message Email Message
If both mobile phone number and email address are provided but no preference is indicated the notification method will default to email.
