Form Cssd 04-0008 - Electronic Fund Transfer (Eft) Authorization For Direct Deposit Or Direct Payment - State Of Alaska

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STATE OF ALASKA
DEPARTMENT OF REVENUE
Check One
CHILD SUPPORT SERVICES DIVISION
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550 W 7th Avenue Ste 310
Anchorage AK 99501-6699
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Phone: (907) 269-6900
Fax: (907) 269-6650
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TTY: (907) 269-6894 TTY In-State Toll-Free 1-800-370-6894
ELECTRONIC FUND TRANSFER (EFT)
AUTHORIZATION FOR DIRECT DEPOSIT OR DIRECT PAYMENT
Only one form is needed even if you have multiple cases
Name as it appears on the bank account ________________________________________________
CSSD member ID # _________________________ Social Security Number____________________
(This the 8 digit Member Number assigned to you by CSSD. It is not your 9 digit case number)
I authorize the State of Alaska to:
make direct deposits to the account below (name on account must match name on the CSSD case)
take direct payments from the account described below.
Name of bank or financial institution: _________________________________________________
Account type:
CHECKING
SAVINGS
OTHER ___________________
Transit routing number and account number (example below): ______________________________
Attach a voided check or deposit slip here
This will be used to verify the name, bank
routing number, and account number
Routing #
Account #
I authorize the State of Alaska to make necessary adjustments to the above account to correct any credit entries made
in error. I understand that the State will make a reasonable effort to notify me within 24 hours when an adjustment
is made. This authority remains in effect as long as I have an open child support case with the State of Alaska or
until the State receives written notice from me.
I understand that 30 days written notice is required to change financial institutions, account numbers, or account
type; that I must notify CSSD if I close my account or change my address; that the name on the child support case
must match the name on the account into which deposits are being made; and that direct deposit will begin only after
the above information has been electronically verified.
______________________________________
______________
__________________
Signature
Date
Day phone
CSSD 04-0008 (Rev. 05/19/04) (1 p.)
Electronic Fund Transfer Authorization

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