Direct Deposit Authorization Form printable pdf download

WI SCTF

TEL:

800-991-5530

PO Box 07914

TDD:

877-209-5209

Milwaukee WI 53207-0914

Authorization Form: Direct Deposit

Please print and complete ALL the information below. We WILL NOT process forms with missing information.

Name: _______________________________________________

Address: _____________________________________________

City/State/ZIP: ________________________________________

Important

Daytime Telephone: (______) _____________________________

You must include a copy of your check

showing the account and routing numbers.

Home Telephone: (______) _______________________________

Write “Void” across your check

Your Child Support PIN Number: _________________________

(Contact your Child Support Agency if you do not know your PIN)

Social Security Number: _________________________________

~ Sample Check ~

Bank Routing Number: __________________________________

Your Name

(See sample check or contact your bank for the routing number)

VOID

Pay to the order of ___________________________________________________________

Bank Account Number: _________________________________

__________________________________________________________________________

(See sample check or contact your bank for the account number)

__________________________________________________________________________

Account Type:

Checking

Savings

(Check One)

:0000000000

00000000000

0000

Bank Name: ___________________________________________

Bank City/State: _______________________________________

Routing

Account

Number

I want to:

Change My Account

Cancel Direct Deposit

(Check One)

I agree: (Check One)

The whole amount of my direct deposit payment will NOT be moved to an account outside the United States.

The whole amount of my direct deposit payment will be moved to an account outside the United States.

Note: By signing this form you authorize the WI Support Collections Trust Fund (WI SCTF) to initiate payments to

the above account. You may check the date your payments were processed by the WI SCTF online at

childsupport.wisconsin.gov or by calling the WI Support Collections Trust Fund at the phone numbers listed above.

It takes at least 2 business days from the date the WI SCTF processes your payment for your bank or credit union to

credit a direct deposit payment to your bank account. It is very rare, but there might be further delays in the direct

deposit of support payments. We recommend that you confirm the direct deposit with your financial institution to be

sure the deposit transaction is complete. You must call your Child Support Agency or the Trust Fund to stop direct

deposit.

You are responsible for ensuring that there are adequate funds in your account before withdrawing funds. The

Department of Children and Families and its vendors are not liable for overdraft fees and charges.

Please sign and date this form, then mail it to the address at the top of the form.

Signature: _____________________________________________

Date: _____________________________

Office Use Only: Sent By: _______________ Date Received ____/____/____ Entered By: ________________

(R. 06/2011)

Direct Deposit Authorization Form

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