Form SDU-012 Authorization Agreement for Automatic Deposits - Illinois

Form SDU-012 or the "Authorization Agreement For Automatic Deposits" is a form issued by the Illinois Department of Healthcare and Family Services.

Download a PDF version of the Form SDU-012 down below or find it on the Illinois Department of Healthcare and Family Services Forms website.

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AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSITS
I hereby authorize the 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):
Checking Account (ATTACH A VOIDED CHECK)
Savings Account (CONTACT YOUR BANK TO OBTAIN THE BANK ROUTING NUMBER AND SAVINGS ACCOUNT NUMBER)
NAME OF BANK ______________________________________________________
PHONE __________________________________________
ADDRESS __________________________________________________
CITY, STATE & ZIP _________________________________________
BANK ROUTING No. _________________________________________
ACCOUNT No. _____________________________________________
9 digit number on the bottom left of your check
Numbers following Routing 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
and in such manner as to afford the SDU and the Bank a reasonable opportunity to act on it.
PRINTED NAME _________________________________________________________________
MAIL AUTHORIZATION TO
S.D.U.
Signature ______________________________________________________________________
PO BOX 5920
Case No. ______________________________
County of Court Order___________________
Carol Stream, IL 60197-5920
Date __________________________________
Social Security No. _____________________
SDU-012 REV. 05/02
Tired of taking time to deposit your child support check? Tired of waiting for the mail to arrive? We have the
solution... Direct Deposit.
With Direct Deposit, the State Disbursement Unit sends a credit to your bank, savings & loan or credit union and your funds are
deposited into your checking or savings account automatically.
Direct Deposit is a safer way of getting your child support payment because your check can’t be lost or stolen. Wherever you
are —traveling on business, away on vacation or sick at home— your money is deposited, automatically.
Signing up for Direct Deposit is easy. Just complete the Direct Deposit authorization form on back of this statement today,
return it to the SDU along with a voided check or savings account information and soon, you’ll be getting your child support
payment the safe and reliable way!
Questions? Give SDU Customer Service a call at 1-877-225-7077
S a fe, S ecu r e, S im p l e!
AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSITS
I hereby authorize the 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):
Checking Account (ATTACH A VOIDED CHECK)
Savings Account (CONTACT YOUR BANK TO OBTAIN THE BANK ROUTING NUMBER AND SAVINGS ACCOUNT NUMBER)
NAME OF BANK ______________________________________________________
PHONE __________________________________________
ADDRESS __________________________________________________
CITY, STATE & ZIP _________________________________________
BANK ROUTING No. _________________________________________
ACCOUNT No. _____________________________________________
9 digit number on the bottom left of your check
Numbers following Routing 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
and in such manner as to afford the SDU and the Bank a reasonable opportunity to act on it.
PRINTED NAME _________________________________________________________________
MAIL AUTHORIZATION TO
S.D.U.
Signature ______________________________________________________________________
PO BOX 5920
Case No. ______________________________
County of Court Order___________________
Carol Stream, IL 60197-5920
Date __________________________________
Social Security No. _____________________
SDU-012 REV. 05/02
Tired of taking time to deposit your child support check? Tired of waiting for the mail to arrive? We have the
solution... Direct Deposit.
With Direct Deposit, the State Disbursement Unit sends a credit to your bank, savings & loan or credit union and your funds are
deposited into your checking or savings account automatically.
Direct Deposit is a safer way of getting your child support payment because your check can’t be lost or stolen. Wherever you
are —traveling on business, away on vacation or sick at home— your money is deposited, automatically.
Signing up for Direct Deposit is easy. Just complete the Direct Deposit authorization form on back of this statement today,
return it to the SDU along with a voided check or savings account information and soon, you’ll be getting your child support
payment the safe and reliable way!
Questions? Give SDU Customer Service a call at 1-877-225-7077
S a fe, S ecu r e, S im p l e!

Download Form SDU-012 Authorization Agreement for Automatic Deposits - Illinois

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