Form Dss-4718 - Direct Deposit Authorization
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1North Carolina Child Support Enforcement Program
DIRECT DEPOSIT AUTHORIZATION
P
. I
LEASE COMPLETE IN BLUE OR BLACK INK
NCOMPLETE OR INCORRECT INFORMATION MAY RESULT
.
. A
3
4
IN A DELAY IN PROCESSING THIS REQUEST
LLOW
TO
WEEKS FOR DIRECT DEPOSIT TO TAKE EFFECT
Until this request is processed, payments will be made by debit card or check.
NAME: __________________________________ _____________________________________ _____
LAST)
(FIRST)
(MI)
(
SOCIAL SECURITY NUMBER______________________________
MPI #______________________
ADDRESS: __________________________________________
HOME PHONE # (____)__________
(
S
/POB)
TREET
________________________________________________________ WORK PHONE # (____)_________
(C
)
(S
)
(Z
C
)
ITY
TATE
IP
ODE
1. C
:
HECK THE TYPE OF REQUEST BELOW
____ S
/C
–
AND
.
TART
HANGE DIRECT DEPOSIT
CHECK TYPE OF ACCOUNT
PROVIDE DOCUMENTATION
____ C
A
– ATTACH
(
);
HECKING
CCT
A VOIDED PREPRINTED CHECK TO THIS FORM
NO STARTER CHECKS
OR
#2
.
#3
.
HAVE THE BANK COMPLETE THE INFORMATION IN
BELOW
READ AND SIGN
BELOW
____ S
A
–
#2
.
#3
.
AVINGS
CCT
THE BANK MUST COMPLETE
BELOW
READ AND SIGN
BELOW
____ S
D
D
–
.
# 3
.
TOP
IRECT
EPOSIT
DO NOT ATTACH A CHECK
PLEASE SIGN
BELOW
2. B
–
ANK INFORMATION
THE BANK MUST COMPLETE THIS SECTION FOR A SAVINGS ACCOUNT OR IF YOU DO
.
NOT HAVE A PREPRINTED CHECK
B
N
___________________________________________________ B
P
# ____________________
ANK
AME
ANK
HONE
B
A
_________________________________________________________________________________
ANK
DDRESS
B
R
N
____ ____ ____ ____ ____ ____ ____ ____ ____
ANK
OUTING
UMBER
B
A
N
________________________________________
ANK
CCOUNT
UMBER
B
R
’
N
(
) ___________________________________________________________
ANK
EPRESENTATIVE
S
AME
PRINTED
_______
B
R
’
S
_________________________________________ Date ___/____/
ANK
EPRESENTATIVE
S
IGNATURE
.
3. A
S
UTHORIZATION AND
IGNATURE
PLEASE READ, SIGN AND DATE. PLEASE DO NOT SEND CORRESPONDENCE WITH THIS
.
DOCUMENT
I hereby authorize the NC Child Support Enforcement program (CSE) to deposit my child support payments to the
financial institution account named above. CSE will make deposits to this bank account until I cancel the authorization
and CSE has time to process the cancellation. I authorize CSE to contact the financial institution and make debit entries
and adjustments for any credit entries made in error to my account. I understand that until this request is processed,
payments will be made by debit card or check.
Y
S
:
__________________________________________
D
:______/______/_______
OUR
IGNATURE
ATE
MAIL SIGNED ORIGINAL COMPLETED FORM TO:
NCCSE –EFT
PO BOX 19807
Raleigh, North Carolina 27619
If you have questions or address changes, call 1-800-992-9457.
DSS-4718 Rev 08/2009
For Office Use Only: Date of Receipt____________________
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