TEXAS Child Support Disbursement Unit DIRECT DEPOSIT Authorization Form DIRECT DEPOSIT Child support payments you receive from the TEXAS CHILD SUPPORT DISBURSEMENT UNIT (TXCSDU) may be sent to you by direct deposit. If you want all payments you receive from the TXCSDU to be directly deposited to your financial institution, complete the Direct Deposit Authorization Form using the following instructions. With the exception of your signature, type or print the requested information. If you need help with completing the Direct Deposit Authorization Form, contact the TXCSDU between 8:00 a.m. and 5:00 p.m., Monday through Friday, at 1-800-252-8014. You may also request assistance from your financial institution in completing the form. Return the form to: TEXAS CHILD SUPPORT DISBURSEMENT UNIT, P.O. BOX 659400, SAN ANTONIO, TX 78265 TEXAS CHILD SUPPORT DIRECT DEPOSIT Authorization Form Please attach Voided Check or Letter from Financial Institution and Sign the bottom of this form prior to Mailing Back to: TXCSDU P.O. Box 659400 San Antonio, TX 78265 Please Print or Type 1. Direct Deposit Action Requested: (CHECK ONE) Start ________ Change ________ Stop ________ For accuracy, please verify information with your financial institution for items 2 – 5 2. Account Type: (CHECK ONE) Checking ________ Keep these instructions and a copy of the completed form for your records. If you do not provide all the information requested, the TXCSDU may not be able to process your Authorization Form. FREQUENTLY ASKED QUESTIONS ABOUT DIRECT DEPOSIT 1. How secure and reliable is direct deposit? Direct deposit is very safe and reliable. It allows money to be electronically transferred from the TXCSDU to your financial institution. Direct deposit eliminates the possibility of lost or stolen checks. With direct deposit, there are no mail delays and no check cashing fees to pay. Savings ________ 3. Account Number: 4. Transit Routing Number: (9 Digits) Please contact your financial institution for this number 5. Name of Financial Institution: Mailing Address: 2. What do I do if I want to change financial institutions or stop my direct deposit? Written requests are required for any change or to stop direct deposit. You must call 1-800-252-8014 for a TXCSDU Authorization Form. Failure to do so may result in disruption of service. Telephone: ( 3. How do I sign up for direct deposit? To sign up for direct deposit, complete the attached Direct Deposit Authorization Form. Instructions are at the top of this form to assist you in completing this form. Make sure you include the financial institution routing number, account number, account type and a voided check, or letter from your financial institution with your form. 7. Name of Payor: (last, first, middle) Non-Custodial Parent 4. How long does it take to set up direct deposit? Once the TXCSDU receives your Authorization Form for direct deposit, please allow thirty (30) days for the conversion from check to direct deposit. 5. How will I know when my payments are being paid by direct deposit instead of by check? Using your CIN # you can verify whether the TXCSDU has sent a payment to your financial institution via direct deposit. You can call the Payment Information Line at 1–800-252–8014. In most cases, funds will be available in your bank account two to three business days after the payment is received at the TXCSDU. 6. Will I be notified when money is deposited in my account? The TXCSDU will not send you a notice each time a payment is deposited to your account. You can verify that a payment was deposited to your account by calling 1-800-252-8014 and/or your financial institution automated system. ) 6. Name of Payee: (last, first, middle) Custodial Parent 8. County assigned Cause Number: (see Court order) 9. Payee Address: (Number and Street) City, State, and Zip Code 10. Payee Telephone Numbers: Work: ( ) Home: ( ) 11. Payee Social Security Number: (Custodial Parent) 12. Signature: Please Mail Form to: TXCSDU P.O. Box 659400 San Antonio, TX 78265 For Additional Information Call: 1-800-252-8014 (Custodial Parent) Date: Signature above signifies agreement with terms and conditions on the reverse side of this form. RQ6A002A-1 December 2003 See information on reverse side American LegalNet, Inc. www.USCourtForms.com By signing this Authorization Form, I consent to the policy of the Office of the Attorney General (OAG) for recovering money sent to me in error. Money sent to me in error, NOT repaid within 30 days of notice of overpayment, will be withheld from future child support payments. I authorize the financial institution to accept the deposit for my account and to make adjustments to my account to correct any error relating to the deposit. I agree and understand that this authorization for direct deposit revokes OAG form 1A004, Authorization For Release of Information with respect to redirection of child support payments. This Authorization form will remain in effect until revoked by me in writing or canceled by the financial institution and supercedes any existing instructions concerning my child support direct deposit. I also understand that I have a responsibility to provide a written request to discontinue direct deposit. To discontinue direct deposit and provide a mailing address for future payments I must call 1-800-252-8014 to request an Authorization Form, or execute OAG form 1A004 if payments are to be directed to a person other than myself. The Authorization form should be returned to the TXCSDU, P.O. Box 659400, San Antonio, TX 78265. I agree that the TXCSDU will have no responsibility for personal checks written against my account prior to the funds being available in my account, and my account will be administered in accordance with the rules and regulations of the financial institution. WARNING: This is a governmental document. Texas Penal Code, Section 37.10, specifies penalties for making false entries or providing false information in this document. American LegalNet, Inc. www.USCourtForms.com