Direct Deposit Form - Idaho

This "Direct Deposit Form" is a document issued by the Idaho Department of Health and Welfare specifically for Idaho residents with its latest version released on February 1, 2017.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Idaho Department of Health and Welfare.

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Revised 02/2017
Child Support payments are disbursed electronically. Complete the Direct Deposit form to have Child Support payments
deposited into your account when Child Support Services receives payment.
I want to sign up for direct deposit
I want to edit my current direct deposit information
Your Information
Name of person to receive payments
Date of birth
Social security number
Phone number
Your Account Information
Complete the account information below of where you would like your payments deposited or attach a voided check to
this application.
Financial institution
Type of Account
Checking
Savings
Address
State
Zip Code
Account holder’s name
Routing Number
Account number
Example:
Provide Authorization
I authorize Wells Fargo Banking Services as designated agent for the Idaho Department of Health and Welfare to deposit
my payments directly in to my personal checking/savings account, and if necessary, reverse any incorrect deposits
related to the Idaho Electronic Payment System. I authorize my financial institution to provide the account information
requested above.
Signature
Date
Submit this form by one of the following methods:
Mail:
Email:
Fax:
Idaho Child Support
SRCU-MDU@dhw.Idaho.gov
1-855-349-2408 (toll free)
Mail Distribution Unit
PO Box 83720
Boise, ID 83720-5302
Revised 02/2017
Child Support payments are disbursed electronically. Complete the Direct Deposit form to have Child Support payments
deposited into your account when Child Support Services receives payment.
I want to sign up for direct deposit
I want to edit my current direct deposit information
Your Information
Name of person to receive payments
Date of birth
Social security number
Phone number
Your Account Information
Complete the account information below of where you would like your payments deposited or attach a voided check to
this application.
Financial institution
Type of Account
Checking
Savings
Address
State
Zip Code
Account holder’s name
Routing Number
Account number
Example:
Provide Authorization
I authorize Wells Fargo Banking Services as designated agent for the Idaho Department of Health and Welfare to deposit
my payments directly in to my personal checking/savings account, and if necessary, reverse any incorrect deposits
related to the Idaho Electronic Payment System. I authorize my financial institution to provide the account information
requested above.
Signature
Date
Submit this form by one of the following methods:
Mail:
Email:
Fax:
Idaho Child Support
SRCU-MDU@dhw.Idaho.gov
1-855-349-2408 (toll free)
Mail Distribution Unit
PO Box 83720
Boise, ID 83720-5302
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