Form Cssd 04-1013 - Cssd Check Reissue Request, Form Cssd 04-0008 - Authorization Form For Visa Debit Card Or Direct Deposit To Bank Account Etc. Page 2

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STATE OF ALASKA
DEPARTMENT OF REVENUE
Check One
CHILD SUPPORT SERVICES DIVISION
New
550 W 7th Avenue Ste 310
Anchorage AK 99501-6699
Change
Phone: (907) 269-6900
Fax: (907) 269-6650
Cancel
TTY: (907) 269-6894 TTY In-State Toll-Free 1-800-370-6894
CUSTODIAL PARENT AUTHORIZATION
FOR DIRECT DEPOSIT
Only one form is needed even if you have multiple cases
Custodial Parent Name ____________________________________________________________
CSSD member ID #
Social Security Number
(This is the 8 digit Member Number assigned to
The disclosure of your social security number on
you by CSSD, not your 9 digit case number).
this form is voluntary. We will use your social
security number to assist in the identification of
your bank or financial account.
I authorize the State of Alaska CSSD to make Direct Deposits to the account below:
(name on account must match the name on the CSSD case)
Name of bank or financial institution: _________________________________________________
Account type:
CHECKING
SAVINGS
OTHER __________________
Transit routing number and account number (example below): ______________________________
You must attach a voided check or deposit slip
This will be used to verify the name, bank
routing number, and account number
Routing #
Account #
I authorize the State of Alaska CSSD 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 CSSD.
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. 10/10/05) (1 p.)
Electronic Fund Transfer Authorization

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