Fillable Printable Direct Deposit Authorization Form - Indiana

Direct Deposit Authorization Form - Indiana

DIRECT DEPOSIT AUTHORIZ ATION

State Form 51519 (R2 / 4-13)

DEPARTMENT OF CHILD SERVICES

* This authorization requests the disclosure of your Social Security number in accordance with IC 4-1-8-1.

Disclosure is mandatory; this record cannot be processed without it.

P.O. Box 6098

Indianapolis, IN 46206-6098

Telephone: 317-233-5437

Toll-free: 1-800-840-8757

Fax: 317-241-9635

Check one

New request Change request

Please compl ete this form and mail it to the address above if you wish to have your suppo rt payments deposited

automatically into your checking or savings account. You may choose only one account to which these funds will be

deposited, regardl ess of the number of child support cases that you have open in the State of Indiana. No separate notice

of deposit will be sent to you when funds are disbursed.

Please keep a copy of this form in your records. If you change

accounts, you must complete a ne w authorization form.

Name of custodial party Social Security Number of custodial party* Daytime telephone number

( )

Home address (number and street) City State ZIP code

Name of your financial institution (bank, credit union, etc.)

Address of your financial institution (number and street) City State ZIP code

Telephone number of your financial institution

( )

Routing number of your financial institution

You may have your payments deposited to one of the following:

Checking account number Savings account number

FOR CHECKING ACC OUNT : You must include a voided check (with your name and account number machine encoded

– we cannot accept “starter” checks that do not have a machine printed name and address). If your account is debit card

only and you do not have checks, you must include a copy of the p ortion of your monthly account statement that shows

your name and accou nt number.

FOR SAVINGS AC COUNT

: You must include a savings accou nt deposit slip (with your name and account number

machine encoded ). If your deposit slip does not have this information, you must include a copy of the portion of your

monthly account statement that shows your name an d account number. If your deposit slip has a number that starts with

a 5, that is not the routing number. You will need to send the portion of your monthly statement with the Bank Routing

number and your account n umber.

Deposits will not begin for at least ten (10) busine ss days after this authorization form is received at the INSCCU in order

to verify information with your financial institution. Each deposit will be available in your bank approximately two (2)

business days from the posting date.

This authorization applies to funds received at the INSCCU and the Clerk of Courts that are using Electro nic Banking to

disburse funds. It does not

apply to funds received in Clerk of Courts offices that are not using Electronic Banki ng.

I authorize the Indiana State Child Support Burea u to initiate debit entries and adjustments for any credit entries in error to

my account, and I authorize the bank to perform those transactions.

Signature of custodial party Date (month, day, year)

If funds are returned by the Financial Institution for any reason (e.g., you have closed your account), Direct Depo sit will be

terminated and these funds w ill be issued by check to your address on the Child Support System. It is your responsibility to

maintain a valid address in the Child Support System by calling the phone number listed above or by contacting the Clerk of

Court where your order resides.