"New York State Child Support Direct Deposit Enrollment Form" - New York

New York State Child Support Direct Deposit Enrollment Form is a legal document that was released by the New York State Department of Financial Services - a government authority operating within New York.

Form Details:

  • Released on April 20, 2015;
  • The latest edition currently provided by the New York State Department of Financial Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the New York State Department of Financial Services.

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Download "New York State Child Support Direct Deposit Enrollment Form" - New York

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New York State Child Support Direct Deposit Enrollment Form
For Direct Deposit ONLY. Do not use this form if you wish to receive a debit card.
Directions:
1.
Complete BOTH sections below and return this form, ONLY if you wish to enroll in Direct Deposit.
2.
Your name must appear on your bank or credit union account.
3.
Your enrollment cannot be processed without your New York Case Identifier.
4.
If you are receiving payments on more than one New York Case Identifier, you will need to complete and submit a separate form for
each case.
5.
Return the completed form to: NYS Child Support Processing Center, PO Box 15367, Albany, NY 12212-5367.
6.
For any questions on how to complete this form, contact the Child Support Helpline at 888-208-4485, TTY 866-875-9975, Video Relay
Service (www.fcc.gov/encyclopedia/trs-providers).
A. Required Information for Enrolling in Direct Deposit to be Completed by the Enrollee
The following information must be provided. If ANY information is missing, the form will be returned for completion.
Your Name
Email Address (optional)____________________________
Phone Number
(________) ___________-_____________
____________________________________________________
_____________________
______
Last
First
MI
Your Mailing Address:
County Name
________________________________________________________
New York Case Identifier
Street
___ ___ ___ ___ ___ ___ __ ___ ___
__________________________________________________________________
City
State
Zip Code
____________________________________________________________________
___________
_________________
Social Security Number
Date of Birth
(MM/DD/YYYY) ____ / ____ / ________
______ - ____ - _________
(Month-Day- Four Digit Year)
I certify that I am entitled to child support, or combined child and spousal support, payments for the above New York Case
Identifier. I authorize that all my child support and/or spousal support payments to the financial institution named below be
deposited in the account indicated by the financial institution. This authorization will remain in force until I provide written notice
of cancellation. I understand and agree to a reasonable time to process the cancellation notice.
Signature _________________________________________________
Date ____ / ____ / ____
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - -- - - -
B. Required Information to be Completed by the Financial Institution
Please take this form to your bank or credit union for the following information and their signature:
Bank Information: Name of Financial Institution (bank or credit union):
_______________________________________________________
Address
City
State
Zip__________
______________________________________________________
___________________________
______
Account Information:
_____Checking
_____Savings
(This CANNOT be a Trust Account to benefit another
or a Foreign Financial Institution Account)
Account Number
Routing Transit Number____ ____ ____ ____ ____ ____ ____ ____ ____
___________________________________
As representative of the above-named Financial Institution, I certify this financial Institution is ACH capable and will receive and
deposit the support payments to the bank account number shown above.
_________________________________________________
_____________________________________________
_______________
Representative Signature
Representative Printed Name
Date
W
DDENROLL 04/20/15
New York State Child Support Direct Deposit Enrollment Form
For Direct Deposit ONLY. Do not use this form if you wish to receive a debit card.
Directions:
1.
Complete BOTH sections below and return this form, ONLY if you wish to enroll in Direct Deposit.
2.
Your name must appear on your bank or credit union account.
3.
Your enrollment cannot be processed without your New York Case Identifier.
4.
If you are receiving payments on more than one New York Case Identifier, you will need to complete and submit a separate form for
each case.
5.
Return the completed form to: NYS Child Support Processing Center, PO Box 15367, Albany, NY 12212-5367.
6.
For any questions on how to complete this form, contact the Child Support Helpline at 888-208-4485, TTY 866-875-9975, Video Relay
Service (www.fcc.gov/encyclopedia/trs-providers).
A. Required Information for Enrolling in Direct Deposit to be Completed by the Enrollee
The following information must be provided. If ANY information is missing, the form will be returned for completion.
Your Name
Email Address (optional)____________________________
Phone Number
(________) ___________-_____________
____________________________________________________
_____________________
______
Last
First
MI
Your Mailing Address:
County Name
________________________________________________________
New York Case Identifier
Street
___ ___ ___ ___ ___ ___ __ ___ ___
__________________________________________________________________
City
State
Zip Code
____________________________________________________________________
___________
_________________
Social Security Number
Date of Birth
(MM/DD/YYYY) ____ / ____ / ________
______ - ____ - _________
(Month-Day- Four Digit Year)
I certify that I am entitled to child support, or combined child and spousal support, payments for the above New York Case
Identifier. I authorize that all my child support and/or spousal support payments to the financial institution named below be
deposited in the account indicated by the financial institution. This authorization will remain in force until I provide written notice
of cancellation. I understand and agree to a reasonable time to process the cancellation notice.
Signature _________________________________________________
Date ____ / ____ / ____
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - -- - - -
B. Required Information to be Completed by the Financial Institution
Please take this form to your bank or credit union for the following information and their signature:
Bank Information: Name of Financial Institution (bank or credit union):
_______________________________________________________
Address
City
State
Zip__________
______________________________________________________
___________________________
______
Account Information:
_____Checking
_____Savings
(This CANNOT be a Trust Account to benefit another
or a Foreign Financial Institution Account)
Account Number
Routing Transit Number____ ____ ____ ____ ____ ____ ____ ____ ____
___________________________________
As representative of the above-named Financial Institution, I certify this financial Institution is ACH capable and will receive and
deposit the support payments to the bank account number shown above.
_________________________________________________
_____________________________________________
_______________
Representative Signature
Representative Printed Name
Date
W
DDENROLL 04/20/15