Hsd-Csed Prepaid Debit Card Enrollment Form printable pdf download

NEW MEXICO HSD-CSED PREPAID DEBIT CARD ENROLLMENT FORM

NEW MEXICO HSD-CSED UNA CUENTA DE TARJETA DE DEBITO PREPAGADA FORMA

Name (please print) __________________________________________________________________________________________

Nombre (por favor escriba en letra de imprenta)

First – Primer Nombre

Middle Initial – Inicial del Segundo Nombre

Last – Apellido

Address ______________________________________________________________________________________ Apt. #________

City___________________________________________________ State ___________________ Zip Code __________________

Ciudad

Estado

Codigo postal

Phone Number (________) _________ Date of Birth ____/_____/_____ Social Security Number (required) ______-_____-______

mer

ono

Fecha de Nacimiento

mero del Seguro Social (requerido)

Child Support

Member Number (required) _______ _______ _______ _______ _______ _______ _______ _______ _______

(This is the 9 – digit Member Number located on your payment stub. Or contact the NM CSED at

1-800-288-7207 in state, or 1-800-585-7631 out of state.)

Numero de Miembro de

(

gitos situado en su

NM CSED en el 1-800-288-7207

Pensión alimenticia para hijos

dentro del estado o al 1-800-585-7631 fuera des estado.)

By signing this form, I authorize the New Mexico Child Support Enforcement Division (“State Agency”) to share information about me with Wells

Fargo Bank, N.A. (“Bank”) for the purpose of establishing a Prepaid Debit Card account (“Prepaid Card’) that will be used by the State Agency for

disbursement of my child support payments. I understand that the Prepaid Card is a voluntary disbursement option provided by the State Agency

and will cancel and replace any direct deposit or check selections I have made previously. I acknowledge that the Prepaid Card is subject to

certain terms, conditions and fees established by Bank and agree to be bound by the terms of the State of New Mexico Prepaid Debit Card

Deposit Agreement from Wells Fargo Bank that will be provided when I receive my Prepaid Card. I have received, read and understand the

Schedule of Fees furnished with this enrollment brochure.

Al firmar esta formulario, autorizo a New Mexico Child Support Enforcement Division (“Agencia del Estado”) para a

n sobre

mi con Wells Fargo Bank, N.A. (“Banco”) con el objeto de establecer una cuenta de Tarjeta de Debito Prepagada (“Tarj

utilizada por la Agencia del estado para el desembolso de mis pagos de pensión alimenticia para hijos. Entiendo que la Tarjeta Prepagada es una

n de desembolso voluntaria proporcionada por la Agencia del Estado y que esta cancelará y reemplazará a cualquier selección de cheque o

depósito directo que yo haya hecho previamente. Reconozco que la Tarjeta

rminos, condiciones y cargos

establecidos por el Banco y estoy de acuerdo en regirme

rminos del

n cuando yo reciba mi Tarjeta Prepagada. He reci

do y comprendido la Lista de

Cargos provista con este fo

Signature (required)____________________________________________________________Date (required)_____________

Firma (requerida)

Fecha (requerida)

[Fax to NM SDU at 505-476-3920]

Hsd-Csed Prepaid Debit Card Enrollment Form

Related Articles

Related forms

Related Categories