CLERK OF ALLEN CIRCUIT COURT Child Support - Room 200 715 S Calhoun Street Fort Wayne IN 46802 (260) 449-7588 Fax (260) 449-3929 New Request______ Change Request______ Stop Request______ DIRECT DEPOSIT AUTHORIZATION FORM Please complete this form and mail it to the address above if you wish to have your support payments deposited automatically into your checking or savings account. You may choose only one account within the State of Indiana to which these funds will be deposited, regardless of the number of child support cases that you have open. This authorization applies to funds received at the State Child Support Bureau and Clerk of Court offices that are using Electronic Banking to disburse funds. Any time this form is submitted, all funds will be directed to that account. No notices will be sent as funds are disbursed. Name Social Security Number Daytime Telephone Number Home Address __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ Name of person(s) who pays support to you Name of your financial institution Address of your financial institution _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ Phone Number of your financial institution Routing Number of your financial institution _______________________________________________ _______________________________________________ You may have your payments deposited to one of the following: Checking account OR Savings account Account # ____________________ Account # ____________________ YOU MUST INCLUDE A VOIDED CHECK (WITH YOUR ACCOUNT NUMBER MACHINE ENCODED) WITH THIS FORM FOR A CHECKING ACCOUNT. FOR A SAVINGS ACCOUNT PROVIDE YOUR FINANCIAL INSTITUTION'S ROUTING NUMBER ALONG WITH THE ACCOUNT NUMBER. Deposits will not begin for at least 10 days after this authorization form is received at the State or County office. Each deposit will be available in your bank approximately three (3) days after the payment is disbursed via the ISETS computer system. Please keep a copy of this form for your records. If you change banking institutions or accounts, you must complete a new authorization form. YOU MUST HAVE A VALID ADDRESS ON YOUR CHILD SUPPORT RECORD AT THE CLERK'S OFFICE FOR THIS ARRANGEMENT TO BE VALID. IT IS YOUR RESPONSIBILITY TO KEEP THE CHILD SUPPORT OFFICE AWARE OF YOUR CURRENT ADDRESS. I authorize the State of Indiana, Child Support Bureau, and/or the Clerk of Allen Circuit Court, to initiate, if necessary, debit entries and adjustments for any credit entries in error to my account in the bank named above and I authorize the bank to perform those transactions. _________________________________________________ (Your Signature) ____________________________________________ (Date) This authorization will remain in effect until I send my written cancellation notice to the Clerk of Allen Circuit Court, at the address indicated above. In no case will this cancellation be effective with respect to funds posted or processed prior to the receipt of my notification. American LegalNet, Inc. www.FormsWorkFlow.com