SD Form 1058 "Direct Deposit Enrollment Form" - South Dakota

What Is SD Form 1058?

This is a legal form that was released by the South Dakota Department of Social Services - a government authority operating within South Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the South Dakota Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of SD Form 1058 by clicking the link below or browse more documents and templates provided by the South Dakota Department of Social Services.

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Download SD Form 1058 "Direct Deposit Enrollment Form" - South Dakota

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SD EForm - 1058
V1
HELP
Complete and use the button at the end to print for mailing.
SOUTH DAKOTA DEPARTMENT OF SOCIAL SERVICES
Office of Energy Assistance
DIRECT DEPOSIT ENROLLMENT FORM
Initial Request
Change Request
I authorize the Department of Social Services to deposit my LIEAP vendor
payments directly into the bank account listed below, and if necessary, reverse any
incorrect credit entries. I understand that a new enrollment form must be
completed to change banking information.
Make necessary address corrections here.
__________________________________
__________________________________
Daytime telephone number _______________________________________________
Your Tax ID or Social Security Number ____________________________________
Name of bank __________________________________________________________
Routing number_________________________________________________________
Account Number________________________________________________________
Bank address ___________________________________________________________
City __________________________ State ___________________ Zip ___________
Bank telephone number __________________________________________________
Your signature __________________________________Date___________________
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Your enrollment cannot be processed without a voided check. Mail this completed
form and a voided check.
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
DID YOU SIGN THIS FORM AND ATTACH A VOIDED CHECK?
1.
PRINT FOR MAILING
CLEAR FORM
SD EForm - 1058
V1
HELP
Complete and use the button at the end to print for mailing.
SOUTH DAKOTA DEPARTMENT OF SOCIAL SERVICES
Office of Energy Assistance
DIRECT DEPOSIT ENROLLMENT FORM
Initial Request
Change Request
I authorize the Department of Social Services to deposit my LIEAP vendor
payments directly into the bank account listed below, and if necessary, reverse any
incorrect credit entries. I understand that a new enrollment form must be
completed to change banking information.
Make necessary address corrections here.
__________________________________
__________________________________
Daytime telephone number _______________________________________________
Your Tax ID or Social Security Number ____________________________________
Name of bank __________________________________________________________
Routing number_________________________________________________________
Account Number________________________________________________________
Bank address ___________________________________________________________
City __________________________ State ___________________ Zip ___________
Bank telephone number __________________________________________________
Your signature __________________________________Date___________________
+++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
Your enrollment cannot be processed without a voided check. Mail this completed
form and a voided check.
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
DID YOU SIGN THIS FORM AND ATTACH A VOIDED CHECK?
1.
PRINT FOR MAILING
CLEAR FORM