"Direct Deposit Enrollment Form" - New York

Direct Deposit Enrollment Form is a legal document that was released by the New York State Office of Temporary and Disability Assistance - a government authority operating within New York.

Form Details:

  • Released on November 1, 2021;
  • The latest edition currently provided by the New York State Office of Temporary and Disability Assistance;
  • 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 fillable version of the form by clicking the link below or browse more documents and templates provided by the New York State Office of Temporary and Disability Assistance.

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Download "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.
(Please type or print clearly using black ink.)
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 child support account in New York State, you will need to complete and submit a
separate form for each child support account. Be sure to include the New York Case Identifier.
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, or to request a debit card, contact the Child Support Helpline at 888-208-4485,
TTY 866-875-9975, Relay Service (fcc.gov/encyclopedia/trs-providers).
A. Required Information for Enrolling in Direct Deposit to be Completed by the Enrollee
You must provide the following information about yourself and your child support account.
If ANY information is missing, the form will be returned for completion.
First Name
MI
Last Name
Mailing Address
City
State
ZIP
Date of Birth (MM/DD/YYYY)
Social Security Number
County Name
New York Case Identifier
(e.g., AB12345C1)
Phone Number
Email Address (Optional)
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 (MM/DD/YYYY)
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):
Mailing 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 (MM/DD/YYYY)
Direct Deposit Enrollment Form (Rev. 11/21)
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.
(Please type or print clearly using black ink.)
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 child support account in New York State, you will need to complete and submit a
separate form for each child support account. Be sure to include the New York Case Identifier.
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, or to request a debit card, contact the Child Support Helpline at 888-208-4485,
TTY 866-875-9975, Relay Service (fcc.gov/encyclopedia/trs-providers).
A. Required Information for Enrolling in Direct Deposit to be Completed by the Enrollee
You must provide the following information about yourself and your child support account.
If ANY information is missing, the form will be returned for completion.
First Name
MI
Last Name
Mailing Address
City
State
ZIP
Date of Birth (MM/DD/YYYY)
Social Security Number
County Name
New York Case Identifier
(e.g., AB12345C1)
Phone Number
Email Address (Optional)
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 (MM/DD/YYYY)
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):
Mailing 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 (MM/DD/YYYY)
Direct Deposit Enrollment Form (Rev. 11/21)