Form CCAP-5 "Direct Deposit Form" - Rhode Island

What Is Form CCAP-5?

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

Form Details:

  • Released on February 1, 2020;
  • The latest edition provided by the Rhode Island Department of Human Services;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CCAP-5 by clicking the link below or browse more documents and templates provided by the Rhode Island Department of Human Services.

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Download Form CCAP-5 "Direct Deposit Form" - Rhode Island

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CCAP-5 Direct Deposit Form
CCAP-5 Rev. 2/2020
Rhode Island Department of Human Services
Office of Child Care
25 Howard Avenue, LP Bldg. 3
rd
Floor
Cranston, R.I. 02920
(401) 462-6877
AUTHORIZATION FOR DIRECT DEPOSIT
PROVIDER INFORMATION
Provider ID:
First Name:
Last Name:
Program Name:
Primary Phone:
Number & Street:
City/Town:
State:
Zip Code:
The Department of Human Services, Office of Financial Management is authorized to initiate Direct Deposit of my Child Care Provider
Payments to my account at the Financial Institution below:
Financial Institution:
(bank or credit union)
Number & Street:
City/Town:
State:
Zip Code:
Account Number:
Business
Personal
PLEASE SELECT AN ACCOUNT TYPE
ATTACH A VOIDED BLANK CHECK from the checking account to which the direct deposit will be made. Your
name and current address must be printed on the check. If you cannot provide a proper voided check, you
must provide a letter from your financial institution, which includes your name, address, bank routing
Checking Account **
number and account number. The letter must be on bank letterhead and signed by a bank representative.
DO NOT SEND DEPOSIT SLIPS OR BANK STATEMENTS. Your name must appear on the account and the
account must be with a United States financial institution.
ATTACH A LETTER FROM YOUR FINANCIAL INSTITUTION with your name, address, bank routing number
and account number. The letter must be on bank letterhead and signed by a bank representative. DO NOT
Savings Account **
SEND DEPOSIT SLIPS OR BANK STATEMENTS. Your name must appear on the account and the account must
be with a United States financial institution.
** If the same payment has been deposited more than once into your account, child care will immediately correct the mistake and
notify you of the removal of the duplicate funds from your account.
Signature of Provider
Date
Printed Name
Position/Title
Please complete this form and submit with all required documentation via email or mail to:
DHS.ChildCare@dhs.ri.gov or DHS Office of Child Care, 25 Howard Avenue, LP Bldg. 3rd Floor, Cranston RI 02920
CCAP-5 Direct Deposit Form
CCAP-5 Rev. 2/2020
Rhode Island Department of Human Services
Office of Child Care
25 Howard Avenue, LP Bldg. 3
rd
Floor
Cranston, R.I. 02920
(401) 462-6877
AUTHORIZATION FOR DIRECT DEPOSIT
PROVIDER INFORMATION
Provider ID:
First Name:
Last Name:
Program Name:
Primary Phone:
Number & Street:
City/Town:
State:
Zip Code:
The Department of Human Services, Office of Financial Management is authorized to initiate Direct Deposit of my Child Care Provider
Payments to my account at the Financial Institution below:
Financial Institution:
(bank or credit union)
Number & Street:
City/Town:
State:
Zip Code:
Account Number:
Business
Personal
PLEASE SELECT AN ACCOUNT TYPE
ATTACH A VOIDED BLANK CHECK from the checking account to which the direct deposit will be made. Your
name and current address must be printed on the check. If you cannot provide a proper voided check, you
must provide a letter from your financial institution, which includes your name, address, bank routing
Checking Account **
number and account number. The letter must be on bank letterhead and signed by a bank representative.
DO NOT SEND DEPOSIT SLIPS OR BANK STATEMENTS. Your name must appear on the account and the
account must be with a United States financial institution.
ATTACH A LETTER FROM YOUR FINANCIAL INSTITUTION with your name, address, bank routing number
and account number. The letter must be on bank letterhead and signed by a bank representative. DO NOT
Savings Account **
SEND DEPOSIT SLIPS OR BANK STATEMENTS. Your name must appear on the account and the account must
be with a United States financial institution.
** If the same payment has been deposited more than once into your account, child care will immediately correct the mistake and
notify you of the removal of the duplicate funds from your account.
Signature of Provider
Date
Printed Name
Position/Title
Please complete this form and submit with all required documentation via email or mail to:
DHS.ChildCare@dhs.ri.gov or DHS Office of Child Care, 25 Howard Avenue, LP Bldg. 3rd Floor, Cranston RI 02920