Idaho Direct Deposit Enrollment Form printable pdf download

For Office Use Only

Client ID #________________

Field Office _______________

Caseload # ________________

Date DD Keyed ____________

Case Mgr Approval _________

IDAHO DIRECT DEPOSIT ENROLLMENT FORM

Instructions:

Section 1 must be completed by participant.

Section 2 must be completed by financial institution (i.e., bank or credit union). A voided check or

statement from your bank is sufficient.

Return completed form to your local Health & Welfare office.

A new enrollment form must be completed if you choose to change financial institutions

or accounts.

SECTION 1 - Case Name Information. (Completed on the individual to whom cash payments are made.)

Case Name: ______________________________________________Birth Date: ____________________

Social Security Number

- _____ Phone #:

I authorize JP Morgan EFS as designated agent for the Idaho Department of Health and Welfare, to deposit my cash

payments directly into my personal checking/savings account and if necessary, reverse any incorrect deposits related to the Idaho

Electronic Payment System. I authorize my financial institution to provide the information in section 2.

Signature

Date

SECTION 2 - Bank Account Information.

To be completed by a representative of your financial institution. This

section does not need to be completed if you have attached a voided check.

Financial Institution

Address

City

State

Zip Code

Type of Account (check one):

Checking

Savings

Account Holder’s Name: __________________________________________________________________

Account Number

Routing/Transit number

I certify the Bank Routing/Transit number and the Personal Bank Account listed above are correct.

Signature of representative

Printed name of representative

Bank/Branch

Phone number

Date

REPORT IMMEDIATELY changes to your banking information or if your account closes.

Idaho Direct Deposit Enrollment Form