"Oklahoma Direct Deposit Enrollment Form" - Oklahoma

Oklahoma Direct Deposit Enrollment Form is a legal document that was released by the Oklahoma Department of Human Services - a government authority operating within Oklahoma.

Form Details:

  • The latest edition currently provided by the Oklahoma Department of Human 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 Oklahoma Department of Human Services.

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Oklahoma Direct Deposit Enrollment Form
YOU ARE CURRENTLY ENROLLED IN THE OKLAHOMA DEBIT MASTERCARD
CARD PROGRAM
®
If you would like to sign up for Direct Deposit, you must complete this form and return it to the address
below:
• You MUST attach either a voided check to have the funds deposited in your checking account or a savings account deposit slip
to have the funds deposited in your savings account.
• Staple or Tape your voided check or savings account deposit slip to this form.
• Your name MUST be pre-printed on the voided check or savings account deposit slip.
• Mail this completed form to:
Conduent for OKDHS Direct Deposit
Dept. SGS
P.O. Box 80589
Austin, TX 78708
REQUIRED INFORMATION FOR DIRECT DEPOSIT
Enrollee Information
First Name:_________________________ MI_____ Last Name_________________________
Social Security Number (SSN) ____ ____ ____- ____ ____ - ____ ____ ____ ___
Oklahoma DHS Case Number (DCN)______________________________________
Account where I want my benefits deposited
Bank or Financial Institution ________________________________________________________
Bank Address ______________________________________________________________________
______________________________________________________________________
Account Type (select one): ____ Checking
____ Savings
Bank Routing/Transit Number: ____ ____ ____ ____ ____ ____ ____ ____ ____
Account Number
(up to 17 digits): ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
You can find your bank information on your checks as shown below:
:
123456789
:
12 34567890
101
Routing/Transit Number
Account Number
I certify that I am eligible to receive payments from the Oklahoma Department of Human Services (OKDHS). I authorize the
OKDHS to send my payments to the financial institution named above to be deposited in the account indicated above. This
authorization will remain in force until Conduent receives a written notice from me asking for termination. Conduent shall
have a reasonable time to process the termination.
Signature: ______________________________________ Date: ________________________
Oklahoma Direct Deposit Enrollment Form
YOU ARE CURRENTLY ENROLLED IN THE OKLAHOMA DEBIT MASTERCARD
CARD PROGRAM
®
If you would like to sign up for Direct Deposit, you must complete this form and return it to the address
below:
• You MUST attach either a voided check to have the funds deposited in your checking account or a savings account deposit slip
to have the funds deposited in your savings account.
• Staple or Tape your voided check or savings account deposit slip to this form.
• Your name MUST be pre-printed on the voided check or savings account deposit slip.
• Mail this completed form to:
Conduent for OKDHS Direct Deposit
Dept. SGS
P.O. Box 80589
Austin, TX 78708
REQUIRED INFORMATION FOR DIRECT DEPOSIT
Enrollee Information
First Name:_________________________ MI_____ Last Name_________________________
Social Security Number (SSN) ____ ____ ____- ____ ____ - ____ ____ ____ ___
Oklahoma DHS Case Number (DCN)______________________________________
Account where I want my benefits deposited
Bank or Financial Institution ________________________________________________________
Bank Address ______________________________________________________________________
______________________________________________________________________
Account Type (select one): ____ Checking
____ Savings
Bank Routing/Transit Number: ____ ____ ____ ____ ____ ____ ____ ____ ____
Account Number
(up to 17 digits): ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
You can find your bank information on your checks as shown below:
:
123456789
:
12 34567890
101
Routing/Transit Number
Account Number
I certify that I am eligible to receive payments from the Oklahoma Department of Human Services (OKDHS). I authorize the
OKDHS to send my payments to the financial institution named above to be deposited in the account indicated above. This
authorization will remain in force until Conduent receives a written notice from me asking for termination. Conduent shall
have a reasonable time to process the termination.
Signature: ______________________________________ Date: ________________________