Fillable Printable Direct Deposit Enrollment Authorization Form - North Carolina
Fillable Printable Direct Deposit Enrollment Authorization Form - North Carolina
Direct Deposit Enrollment Authorization Form - North Carolina
Direct Deposit Enrollm ent Authorization For m
North Carolina De part ment of Health and Human Services
DSS 5023 (05-2013)
For County Use Only
Case No: ______ _______________ CNDS No. ___ _______________________
Circle the applicable program area: WFFA SA SA In-Home RCA
Effective July 2013, Special Assistance (SA) including SA In-Home, Refugee Cash Assistance (RCA) and Work First Family Assistance (WFFA)
payments will beg in the change fro m paper checks to electronic payments. Payments will be issued as a Direct Deposit to your pers onal
savings or checking account.
Section 1 (to be completed by Payee/Case Head)
Nam e of Case Head (last, first , mi dd le initial)
Soc i al Security Number (SSN)
Hom e telephone number
Name of Pa yee ( if d i ffer ent th an Case Head)
Payee’s SSN
Gender
DOB
Pref erred l anguage
Type of Account
□
Checking
□
Savings
Acc ount Number:
Name(s) on Account
Bank Name
Case Head/ P ayee’s Address (street, route , P.O. Box)
City/State/Zip code
Payee’s Telephone Number
I hereby authorize the _____________________________ Department of Social Servi ces (DSS) to make deposits to this bank account.
DSS may make deposits to this account until I cancel this authorization.
Attach one of the foll owing
□ I have attached a voided or cancel led check with my name , routing and bank account number preprinted by the bank.
Pr int Name
Signature
Date
Print Name of Payee ( if different than Case Head)
Signature
Date
Section 2 (to be completed by the bank if a cancelled or voided check is not attached or if depositing to a Savings Account)
Nam e and Address of Financial Institution
Routing Num ber: _______________________________ __________________________
Acc ount Number: _________________________________________________________
Name( s) on Account
Type of Account:
□
Chec k ing
□
Savings
Print or Type Bank Representat i ve’s Name
Signature
Telephone Num ber
Date
Direct Deposit will help you in many ways
• You will get your money faster.
• You do not need to make extra trips to the bank or wait
in long lines.
• Your check cannot be lost or stolen.
Here’s how Direct Deposit works
Each month when your check is ready to be mailed to you, the
Departmen t of Social Services (DSS) will electronically deposit
funds directly into your checking or savings account. A separate
notice is not sent to you when funds are paid.
Bank Fees
While Direct Deposit is free, some banks charge fees for
accounts. Make sure you understand the bank rules and fees
that will apply to your account.
Who can sign up for Direct Deposit?
Households that have a checking or savings account.
How many Direct Deposits accounts can I open?
You can chose only one account for each program payment.
How to sign up for Direct Deposit
• Complete Section 1.
• Attach a voided or cancelled check for the checking
account (starter/counter checks cannot be used).
• Have your bank complete Section 2 if you do not attach a
voided check or if arranging Direct Deposit to a Savings
Account.
• Remember to sign and date the form.
• The case name on the Work First, RCA or the name of the
person receiving SA (or the substitute payee) must be on
the bank account.
• Once the form is complete, return it to your caseworker.
• Keep a copy for your records.
When will Direct Deposit Start?
DSS will notify you when your initial request is set up. (You must
complete a new form if you change your account.)
Stopping Direct Deposit
Request a form from your local DSS to cancel your direct deposit
authorization. Allow 30 days from the day the agency receives the
request for the Direct Deposit to stop.
