CSE-1012CORNA (12-03) ARIZONA DEPARTMENT OF ECONOMIC SECURITY Division of Child Support Enforcement AUTHORIZATION TO STOP DIRECT DEPOSIT IV-D case (if you receive or have received cash assistance in the past, and/or have applied for IV-D services, your case is considered a IV-D case.) Non IV-D case (if you have never received cash assistance in the past or have never applied for IV-D services, your case is considered a Non IV-D case.) I no longer wish to participate in the direct deposits of my support checks. I understand that my checks will be sent via US mail to the address below which may delay receipt of checks up to five working days. I understand that an incomplete address will result in non-delivery of my support payments. PLEASE NOTE: When requesting to stop direct deposits, allow four to six weeks for changes to take effect. If you fail to provide all the information requested on this form, your request will not be processed and this form will be returned to you at the address provided below. NAME (Last, First, MI) ATLAS CASE NUMBER CURRENT MAILING ADDRESS SOCIAL SECURITY NUMBER CITY ST ZIP - TELEPHONE NUMBER ROUTING NUMBER - FINANCIAL INSTITUTION NAME ACCOUNT NUMBER PRIMARY OWNER’S NAME (If different than above) SECONDARY ACCOUNT OWNER’S NAME (Last, First, MI) Sign and mail or fax the completed form to your local Clerk of Court or to the Division of Child Support Enforcement (DCSE), as appropriate. However, if you are faxing the request, the original should follow by mail. A listing of local Clerks of Court and/or DCSE is on the reverse side. SIGNATURE DATE FOR OFFICIAL USE ONLY IV-D Case Non IV-D Case Equal Opportunity Employer/Program This document available in alternative formats by contacting (602) 274-3792 Page 1 of 2 Form #417 LRD 11/16/2005 ALL RIGHTS RESERVED © Clerk of Superior Court of Arizona in Maricopa County American LegalNet, Inc. www.USCourtForms.com AUTHORIZATION FORM SUBMITTAL LOCATIONS All IV-D Cases DCSE/Clearinghouse ATTN.: Accounts Receivable P.O. Box 36626 Phoenix, AZ 85067 Phone: (602) 252-4045 FAX: (602) 274-8327 All non-IV-D Cases Apache Clerk of Court P.O. Box 365 St. Johns, AZ 85936 Phone: (928) 337-7550 Graham Clerk of Court 800 Main Street - Courthouse Safford, AZ 85546 Phone: (928) 428-3100 Mohave Clerk of Court P.O. Box 7000 Kingman, AZ 86402 Phone: (928) 753-0713 Ext. 4213 Santa Cruz Clerk of Court P.O. Box 1265 Nogales, AZ 85628 Phone: (520) 375-7701 Cochise Clerk of Court P.O. Drawer CK Bisbee, AZ 85603 Phone: (520) 432-8600 Greenlee Clerk of Court P.O. Box 1027 Clifton, AZ 85533 Phone: (928) 865-4242 Navajo Clerk of Court P.O. Box 668 Holbrook, AZ 86025 Phone: (928) 524-4186 Yavapai Clerk of Court 120 South Cortez Prescott, AZ 86303 Phone: (928) 771-3312 Coconino Clerk of Court 200 N. San Francisco St. Flagstaff, AZ 86001 Phone: (928) 779-6541 La Paz Clerk of Court 1316 Kofa Ave, Suite 607 Parker, AZ 85344 Phone: (928) 669-6131 Pima Clerk of Court 110 W. Congress Tucson, AZ 85701 Phone: (520) 740-3250 Yuma Clerk of Court 250 W. 2nd St., Suite B Yuma, AZ 85364 Phone: (928) 817-4210 Gila Clerk of Court 1400 E. Ash Street Globe, AZ 85501 Phone: (928) 425-3231 Ext. 8553 Maricopa Clerk of Court 201 W. Jefferson Phoenix, AZ 85003 Phone: (602) 506-8868 Pinal Clerk of Court P.O. Box 2730 Florence, AZ 85232 Phone: (520) 866-6309 Page 2 of 2 Form #417 LRD 11/16/2005 ALL RIGHTS RESERVED © Clerk of Superior Court of Arizona in Maricopa County American LegalNet, Inc. www.USCourtForms.com