Authorization to Cancel Electronic and Bank-By-Mail Direct Deposit (12/19/03) CCSD 0002 OFFICE OF THE CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Child Support 28 North Clark Street Room 200 Chicago, Illinois 60602 Phone: (312) 603-2000 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 our system until further instructions are received. NAME: ______________________________________________________ COURT DOCKET NUMBER: ___________________________________ DAY TIME PHONE NUMBER: (________) _________________________ BANK NAME: _________________________________________________ BANK CITY: __________________________________________________ BANK ROUTING NUMBER: _____________________________________ ACCOUNT NUMBER:___________________________________________ TYPE OF ACCOUNT (CIRCLE ONE) CHECKING SAVINGS ________________________________________ ______/______/______ SIGNATURE DATE SIGNED NOTARY: Please put your seal in this space Subscribed and sworn to before me this: _______ day of ___________________, ________ My commission expires ______/______/______ Check if seal is embossed ! ______________________________________ Notary Public Signature =========================================== FOR COMPANY USE ONLY Old & New Att’d: __________________________ Deleted from PNDD on: ______/______/______ Terminated from SDU on: ______/______/______ Deleted from T-KIDS on: ______/______/______ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Print This Form For your protection and privacy, please press the Clear This Form button after you have printed the form. Clear This Form