Form 032-03-0672-03-ENG "Direct Deposit Enrollment Authorization" - Virginia

What Is Form 032-03-0672-03-ENG?

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

Form Details:

  • Released on July 1, 2005;
  • The latest edition provided by the Virginia 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 printable version of Form 032-03-0672-03-ENG by clicking the link below or browse more documents and templates provided by the Virginia Department of Social Services.

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Download Form 032-03-0672-03-ENG "Direct Deposit Enrollment Authorization" - Virginia

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COMMONWEALTH OF VIRGINIA
DEPARTMENT OF SOCIAL SERVICES
TEMPORARY ASSISTANCE FOR NEEDY FAMILIES
DIRECT DEPOSIT ENROLLMENT AUTHORIZATION
Direct Deposit, also known as electronic funds transfer,
How do I sign up for Direct Deposit?
allows the Department of Social Services (DSS) to
Fill out Section 1. Bring this completed form and a
electronically deposit your TANF payments directly into
voided or cancelled check to your interview with your
your checking or savings account.
eligibility worker. Section 2 must be completed by the
bank if you do not have a voided check or want your
benefits direct deposited to your savings account.
Why should I sign up for Direct Deposit?
You will get your money faster because mailing is
When will my Direct Deposit start?
eliminated.
DSS will notify you when your request is set up.
Your
You do not need to make extra trips to the bank
Direct Deposit will start within 30 days after the bank
or wait in long lines.
tells DSS that your account is valid.
Your check cannot be lost or stolen.
How do I stop Direct Deposit?
You must notify your local DSS in writing or you may
How does Direct Deposit work?
request the Direct Deposit Cancel Request form at your
Each month when your TANF check is ready to be mailed to
DSS agency. If you notify the agency in writing,
you, DSS will electronically deposit funds directly into your
include your name, address, date, and social security
checking or savings account.
number. Allow 30 days from the day the agency
receives the request for your Direct Deposit to stop.
Who can sign up for Direct Deposit?
Each TANF case that has a checking or savings account may
How many Direct Deposit accounts can I open?
be signed up for Direct Deposit.
A TANF case can only have one Direct Deposit account
at a time. All payments will go into the one account
Bank Fees
until Direct Deposit is stopped.
While Direct Deposit is free, some banks charge fees for
accounts. Make sure you understand the guidelines and fees
The case name on the TANF case has to be on the
that will apply to your account.
checking or savings account.
SECTION 1 (TO BE COMPLETED BY PAYEE/CASE NAME)
NAME OF PAYEE (last, first, middle initial)
TYPE OF ACCOUNT:
CHECKING
SAVINGS
ADDRESS (street, route, P.O. Box)
ACCOUNT NUMBER:
CITY
STATE ZIP CODE
SOCIAL SECURITY NUMBER:
---
---
HOME PHONE #
WORK PHONE #
I hereby authorize the ______________________Department of Social Services to make deposits to this bank account.
DSS may make deposits to this account until I cancel this authorization.
Must attach one of the following:
I have attached a voided or cancelled check with my name and bank account number preprinted by the bank.
SIGNATURE
DATE
SECTION 2 (TO BE COMPLETED BY THE BANK IF A CANCELLED OR VOIDED CHECK IS NOT ATTACHED
OR IF ARRANGING DIRECT DEPOSIT TO A SAVINGS ACCOUNT)
ROUTING NUMBER
NAME AND ADDRESS OF FINANCIAL
INSTITUTION
ACCOUNT NUMBER
Name(s) on the Account
___________________________________________
_______________________________________
PRINT OR TYPE REPRESENTATIVE’S NAME
SIGNATURE OF REPRESENTATIVE
TELEPHONE NUMBER
DATE
032-03-0672-03-eng (7/05)
COMMONWEALTH OF VIRGINIA
DEPARTMENT OF SOCIAL SERVICES
TEMPORARY ASSISTANCE FOR NEEDY FAMILIES
DIRECT DEPOSIT ENROLLMENT AUTHORIZATION
Direct Deposit, also known as electronic funds transfer,
How do I sign up for Direct Deposit?
allows the Department of Social Services (DSS) to
Fill out Section 1. Bring this completed form and a
electronically deposit your TANF payments directly into
voided or cancelled check to your interview with your
your checking or savings account.
eligibility worker. Section 2 must be completed by the
bank if you do not have a voided check or want your
benefits direct deposited to your savings account.
Why should I sign up for Direct Deposit?
You will get your money faster because mailing is
When will my Direct Deposit start?
eliminated.
DSS will notify you when your request is set up.
Your
You do not need to make extra trips to the bank
Direct Deposit will start within 30 days after the bank
or wait in long lines.
tells DSS that your account is valid.
Your check cannot be lost or stolen.
How do I stop Direct Deposit?
You must notify your local DSS in writing or you may
How does Direct Deposit work?
request the Direct Deposit Cancel Request form at your
Each month when your TANF check is ready to be mailed to
DSS agency. If you notify the agency in writing,
you, DSS will electronically deposit funds directly into your
include your name, address, date, and social security
checking or savings account.
number. Allow 30 days from the day the agency
receives the request for your Direct Deposit to stop.
Who can sign up for Direct Deposit?
Each TANF case that has a checking or savings account may
How many Direct Deposit accounts can I open?
be signed up for Direct Deposit.
A TANF case can only have one Direct Deposit account
at a time. All payments will go into the one account
Bank Fees
until Direct Deposit is stopped.
While Direct Deposit is free, some banks charge fees for
accounts. Make sure you understand the guidelines and fees
The case name on the TANF case has to be on the
that will apply to your account.
checking or savings account.
SECTION 1 (TO BE COMPLETED BY PAYEE/CASE NAME)
NAME OF PAYEE (last, first, middle initial)
TYPE OF ACCOUNT:
CHECKING
SAVINGS
ADDRESS (street, route, P.O. Box)
ACCOUNT NUMBER:
CITY
STATE ZIP CODE
SOCIAL SECURITY NUMBER:
---
---
HOME PHONE #
WORK PHONE #
I hereby authorize the ______________________Department of Social Services to make deposits to this bank account.
DSS may make deposits to this account until I cancel this authorization.
Must attach one of the following:
I have attached a voided or cancelled check with my name and bank account number preprinted by the bank.
SIGNATURE
DATE
SECTION 2 (TO BE COMPLETED BY THE BANK IF A CANCELLED OR VOIDED CHECK IS NOT ATTACHED
OR IF ARRANGING DIRECT DEPOSIT TO A SAVINGS ACCOUNT)
ROUTING NUMBER
NAME AND ADDRESS OF FINANCIAL
INSTITUTION
ACCOUNT NUMBER
Name(s) on the Account
___________________________________________
_______________________________________
PRINT OR TYPE REPRESENTATIVE’S NAME
SIGNATURE OF REPRESENTATIVE
TELEPHONE NUMBER
DATE
032-03-0672-03-eng (7/05)
ENROLLMENT AUTHORIZATION AGREEMENT INSTRUCTIONS
FORM NUMBER - 032-03-0672-03-eng
PURPOSE OF THE FORM - The form authorizes electronic deposit of funds into the client’s bank
account. The form explains TANF Direct Deposit. Section 1 of the form records the client’s name,
address, city, type of bank account, bank account number, bank routing number, social security
number, home telephone number, work phone number and the client's signature.
Section 2 of the form records information for the name and address of the bank, routing number of the
bank, names on the account, bank representative name and signature and the date. A bank
representative must complete Section 2 of the form if the client does not have a voided check or wants
benefits direct deposited in to a savings account.
USE OF FORM – The information is used to process a Direct Deposit request. The form must be
signed by the client before Direct Deposit can be processed. A voided check or deposit slip must be
attached to the completed form.
NUMBER OF COPIES – Original and 1 copy.
DISPOSITION OF COPIES - Original will be put into client’s record and a copy is given to the client.
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