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Direct Deposit Enrollment Form - Office Of Child Support Enforcement (Ocse) Of State Of Arkansas Page 2

State of Arkansas

For Office Use Only:

Office of Child Support Enforcement (OCSE)

Member ID _____________

Direct Deposit Enrollment Form

Keyed _________________

Date

Please print the following information:

___________________________ _________________________

_______________

CUSTODIAL PARENT (CP) NAME

CP SOCIAL SECURITY NUMBER*

CP PHONE #

CASE NUMBER(S): ______________________________________________________

CURRENT MAILING ADDRESS: ___________________________________________

___________________________________________

Check the appropriate information (check all that apply):

New Enrollment

Re-enrollment

Cancel

Checking Account

Savings Account

Change of Financial Institution

Change of Account Number

You must SIGN and DATE the below application and attach a voided check or savings

withdrawal slip reflecting the encoded Bank Routing and Account numbers. Please staple the

voided check or withdrawal slip to the back of this page.

*The disclosure of your Social Security number is not mandated, but it is requested for proper

identification and for the accurate and prompt processing of your request.

MY SIGNATURE BELOW INDICATES MY UNDERSTANDING AND AGREEMENT TO

THE FOLLOWING:

1. I hereby authorize the Office of Child Support Enforcement (OCSE) to disburse child

support payments by sending for deposit payments to the account indicated on the voided

check or withdrawal slip provided. I also authorize my Financial Institution to credit the net

amount to my account. This authority will remain in full effect until OCSE has received

written notification from me of its termination.

2. New enrollments or changes in Financial Institutions will go into effect within 14 business

days from the date the form is received by OCSE.

________________________________

_______________________

Signature

Date

(Rev. 04/11)

Direct Deposit Enrollment Form - Office Of Child Support Enforcement (Ocse) Of State Of Arkansas Page 2