Direct Deposit Authorization Form New Change Cancel (Check One Box Above and Complete the Balance of the Form in its Entirety) Your Name (Please Print): Last First Middle Phone Numbers: Home Phone Work Phone Other Phone Current Address: Number/Street/Apt# City Social Security Number: State/Zip Country (if not US) Case ID or Court Case (Docket) #: (Identify One Case Number, but Multiple Cases May be Paid in a Single Deposit.) Number County Bank Name: Bank Account Number: Bank Routing Number: Checking Savings For a CHECKING account: Write VOID on an unused check and attach here 1234 John and Mary Jones 123 Main Street Anytown, MI 48888 Pay to: For a SAVINGS account: Contact your bank. Obtain written verification of your account and routing numbers from your bank. Attach that verification to this form. $ VOID DOLLARS Anytown Bank Anytown, MI 48888 For: Do Not Complete Shaded Area |: 072412345 |: 0012300456 ” ’ 1234 Routing Number (9 digits) Account Number (up to 17 digits) I authorize the State of Michigan to deposit all support-related payments due me into the designated financial institution and account, and, if necessary, to initiate correcting entries, in case duplicates or other error transactions occur. I understand that the deposits will be made electronically, under the rules of the National Automated Clearing House Association (NACHA), and the State of Michigan. This authorization will remain in effect until cancelled by me with written notification to the state, or cancelled by the financial institution or the State of Michigan, at which time they will notify me by mail at the most current address they have on file for me. Sign Here: AT 2006-012 Attachment 5 DATE: Mail this Form to: MiSDU Attn: Direct Deposit PO Box 30354 Lansing, MI 48909 – 7854 FAX: 517-318-4697 American LegalNet, Inc. www.FormsWorkflow.com