Marion County Clerk’s Office Accounting Department 200 East Washington Street, W-123 Indianapolis, IN 46204 Fax (317) 327-4813 www.indy.gov/clerk Phone (317) 327-8090 ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION FORM Complete this form and mail to the address above if you wish your child support payments be deducted from your account. Name: Social Security Number: Home Address: Daytime Telephone: Name of person you pay child support: Name of your financial institution: Address: Phone: Checking Account Number*: * Must include a voided check or deposit slip and a copy of a valid federal or state picture ID with this form. Deduction Amount: $ Payment Options (check one): Weekly (on Friday) Biweekly (on Friday) Semimonthly (15th and last business day of each month) First day of the month Tenth day of the month Thirtieth day of the month Twentieth day of the month Please note: If the designated payment 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. I authorize the Marion County Clerk to initiate deductions from my account in the bank named above, and I authorize the bank to perform those transactions. Signed: This authorization will remain in effect until I send my written cancellation notice to the Marion County Clerk. In no case can my cancellation be effective with respect to entries processed by the Clerk prior to the receipt of my notification. UI understand that I have the right to have an 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 available in the banking account for this transaction. Rev 4-09 American LegalNet, Inc. www.FormsWorkflow.com