COURT COUNTY . . . . . . . . . . . .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . TEXAS CHILDIndex No. SUPPORT DIRECT DEPOSIT : TEXAS Child Support Disbursement Unit DIRECT DEPOSIT Authorization Form Authorization Form : Please attach Voided Check or Letter from Calendar No. DIRECT DEPOSIT Financial Institution and Sign the bottom of : Child support payments you receive from the TEXAS CHILD this JUDICIAL SUBPOENA Plaintiff(s) form prior to Mailing Back to: 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. TXCSDU P.O. Box 659400 San Antonio, TX 78265 : -against- Please Print or Type 1. Direct Deposit Action Requested: (CHECK ONE) : Start ________ Change ________ Stop ________ 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 Defendant(s) through Friday, at 1-800-252-8014. You may also request assistance : . . . . . . . . . . . . . . . . . . . . form. from your financial.institution in.completing the . . . . . . . . . . . . . . . . . . . . . . . . . .accuracy, please verify information with your financial For . . . . . . institution for items 2 – 5 Return the form to: TEXAS CHILD SUPPORT DISBURSEMENT UNIT, P.O. BOX 659400, SAN ANTONIO, TX 78265 2. Account Type: (CHECK ONE) Checking ________ Keep these THE PEOPLEaOF THE STATE OFform for YORK instructions and copy of the completed NEW your records. TO If you do not provide all the information requested, the TXCSDU may not be able to process your Authorization Form. Savings ________ 3. Account Number: 4. Transit Routing Number: (9 Digits) Please contact your financial institution for this number FREQUENTLY ASKED QUESTIONS ABOUT DIRECT DEPOSIT GREETINGS: 1. How secure and reliable is direct deposit? Direct deposit is very safe and reliable. It allows money to be electronically transferredWE COMMAND your financial institution. from the TXCSDU to YOU, that all business Direct deposit eliminates the possibility of lost or stolen checks. With the Honorable delays and no check cashing fees to direct deposit, there are no mail located at County of pay. in room , on the day of 2. What do I do if I want to change financial institutions or stop or adjourned date, to testify and give evidence as 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. 5. Name of Financial Institution: and excuses being laid aside, you and each of you attend before Mailing Address: Court , at the , 20 , at o'clock in the noon, and at any recessed Telephone: ) a witness in this( action on the part of the 6. Name of Payee: (last, first, middle) Custodial Parent 3. How do I sign up forYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to direct deposit? 7. Name of Payor: (last, first, middle) Non-Custodial Parent To sign up the direct deposit, complete the this subpoenaDeposit for party on whose behalf attached Direct was issued for a maximum penalty of $50 and all damages sustained as a Authorization Form. Instructions are at the top of this form to assist you result of Make sure you include the in completing this form.your failure to comply. financial institution routing number, account number, account type and a voided check, or 8. County assigned Cause Number: (see Court order) letter from your financial institution with your form. Witness, Honorable 4. How long does it take to set up direct deposit? Court in County, day of 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. , one of the Justices of the , 20 9. Payee Address: (Number and Street) City, State, and Zip Code (Attorney must sign above and type name below) 10. Payee Telephone Numbers: Work: ( Attorney(s) for ) Home: ( ) 11. Payee Social Security Number: (Custodial Parent) Office and P.O. Address12. 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: Telephone No.: Signature above signifies agreement with terms and conditions on the reverse sideFacsimile No.: of this form. E-Mail Address: Tel. No.: RQ6A002A-1 DecemberMobile 2003 See information on reverse side American LegalNet, Inc. www.USCourtForms.com Defendant(s) : ...................................................... 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 OF THE STATE OF my account to correct any error relating to the deposit. THE PEOPLE to make adjustments to NEW YORK 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. TO 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. GREETINGS: 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. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the 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. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Court in Witness, Honorable County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com