Authorization to Cancel Electronic and Bank-By-Mail Direct Deposit (Rev. 08/14/15) CCSD 0002 OFFICE OF THE CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Child Support 50 West Washington Street Room LL-01 Chicago, Illinois 60602 Telephone: (312) 345-4015 Fax: (312) 345-4146 AUTHORIZATION TO CANCEL ELECTRONIC AND BANK-BY-MAIL DIRECT DEPOSIT Please write the account number you want us to cancel on this form! I am currently a participant in the Clerk's and/or SDU's direct deposit program, but hereby request to be cancelled from this program. I understand that my child support payments will be mailed to the address on your system until further instructions are received. Name: _____________________________________________________________________ Court Docket Number: ______________________________________________________ Day Time Telephone Number: (________) ________________________________________ Bank Name: _________________________________________________________________ Bank City:__________________________________________________________________ Bank Routing Number: _______________________________________________________ Account Number: ___________________________________________________________ Type of Account: q Checking q Savings _____/_____/_____ Date signed ____________________________________ Signature NOTARY: Please put your seal in this space. Subscribed and sworn to before me this: _____ day of _______________________, ________ Commission expires _____/_____/_____ Check if seal is embossed q ______________________________________ Notary Public Signature ====================================================== FOR COMPANY USE ONLY Old & New Att'd: ___________________________________ Terminated from SDU on: _____/_____/_____ Deleted from PNDD on: _____/_____/_____ Deleted fom T-KIDS on: _____/_____/_____ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 1 of 1