Electronic Payment Authorization Form. This is a Arizona form and can be use in Maricopa Local County.
Tags: Electronic Payment Authorization, 405, Arizona Local County, Maricopa
CSE-1129A FORFF (2-19) Page 1 of 2 ARIZONA DEPARTMENT OF ECONOMIC SECURITY Division of Child Support Services (DCSS) Arizona State Disbursement Unit ELECTRONIC PAYMENT AUTHORIZATION Check applicable box(es): Direct Deposit Only NEW Direct Deposit authorization/set-up STOP Direct Deposit and START EPCCHANGE to bank account information ONLYELECTRONIC PAY CARD (EPC) ONLY NEW EPC set-up STOP EPC and START Direct Deposit UPDATE EPC contact information REPLACE an Electronic Pay Card If you fail to provide all the information requested below, your request will not be processed and this form will be returned to you. Name (Last, First, M.I.) Contact222s Phone No. Custodial Parent222s Date of Birth (MM/DD/YYYY) SOC. SEC. NO. Atlas Case No. Current Mailing Address (No., Street) City State ZIP Code DIRECT DEPOSIT ONLY All of your child support payments and, if applicable, spousal maintenance will go through direct deposit. They will be deposited into one account only, which can be a savings or checking account. If you wish funds to be deposited to your checking account, please attach a personal check marked 223VOID224 and complete the following information. If you and account number. if a check is not available. I HEREBY AUTHORIZE the Arizona State Disbursement Unit (SDU) or its agent designated to initiate credit entries and, if necessary, debit entries and adjustments for any credit entries made in error to my (our) Checking Savings Account indicated below, to credit and/or debit the same to such account for the purpose of support payments. ABA Bank Routing No./Account No. Name of Financial Institution First Name on Account (Last, First, M.I.) Second Name on Account (Last, First, M.I.) terminated by DCSS or its agent by mailing notice to the last mailing address I provided to DCSS or its agent. I will keep the Arizona State Disbursement Unit or its agent informed of any address change that may occur. I understand that failure to do so will result in undelivered support payments. I have received and understand the fee disclosure associated with having an EPC. Print Your Name Your Signature Date RETURN SIGNED FORM TO: ARIZONA STATE DISBURSEMENT UNIT (SDU) Electronic Payment Authorization Unit P.O. Box 36626 Phoenix, AZ 85067-6626 For questions regarding this form or this process, please contact Customer Service at 602-252-4045. See reverse for EOE/ADA/LEP/GINA disclosures American LegalNet, Inc. www.FormsWorkFlow.com CSE-1129A FORFF (2-19) Page 2 of 2 Equal Opportunity Employer/Program 225 Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. To request this document in alternative format or for further information about this policy, contact the Division of Child Support Services at 602-252-4045; TTY/TDD Services: 7-1-1. 225 Free language assistance for DES services American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com