CLERK OF ALLEN CIRCUIT COURT Child Support - Room 200 715 S Calhoun Street Fort Wayne IN 46802 (260) 449-7588 Fax (260) 449-3929 ELECTRONIC FUNDS TRANSFER AUTHORIZATION FORM Complete this form and mail to the address above if you wish your child support payments to be deducted from your account. Your Name ____________________________________________________________________ Your Social Security Number ____________________________________________________________________ Home Address ____________________________________________________________________ ___________________________________________________________________ Daytime Telephone Number ____________________________________________________________________ Name of person you pay Child Support to ________________________________________________________ Name of your financial institution ________________________________________________________ Address of your financial institution ________________________________________________________ _______________________________ Telephone________________ Routing Number of your financial institution ________________________________________________________ Your checking account number** OR savings account number ______Weekly (on Friday) Once a month ________________________________________________________ ______Bi-weekly (on Friday) ______Semi-monthly (15th and last business day) ______First day of the month ______Tenth day of the month ______Twentieth day of the month ______Thirtieth day of the month Amount to be deducted $_____________________ If the designated date falls on a weekend or holiday, the deduction will be effective the next business day. Deductions will not begin for at least fifteen days after this authorization form is received. ** You must include a voided check or deposit slip with this form. I authorize the Clerk of Allen Circuit Court to initiate deductions from my account in the bank named above, and I authorize the bank to perform those transactions. Signed: ___________________________________________ Date______________________________________ This authorization will remain in effect until I send my written cancellation notice to the Clerk of Allen Circuit Court. In no case can my cancellation be effective with respect to entries processed by the Clerk prior to the receipt of my notification. I understand that I have the right to have any erroneous deduction immediately credited to my account by the financial institution within 15 days following issuance of my account statement, or 45 days after posting, whichever occurs first. I understand funds must be in the banking account for transactions. American LegalNet, Inc. www.FormsWorkFlow.com