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 3

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STATE OF ALASKA
Department of Revenue
Child Support Services Division
Only one form is needed even if you have multiple cases
Order your DPC Visa Debit Card today!
It's more convenient than a check. No approval required.
It's easy .. just follow these three steps to a DPC Visa
Debit Card loaded with your child support payments.
1.
Fill out the attached Authorization Form.
Just be sure
to sign and date the form, and then mail it back to the
address on the left.
2.
Watch the mail.
Your card should arrive in a plain white
envelope in about ten days. Activate your card by calling
For more information,
the toll-free number listed on the back of the card.
Call the Alaska Child Support
Services Division at (907) 269-6750
Start using your
card. Future child support payments
3.
will be loaded automatically to your new card. Use it at
Mail the Authorization Form to:
grocery stores, gas stations, restaurants, department stores,
Child Support Services Division
th
pharmacies … anywhere Visa debit cards are accepted.
550 W 7
Ave, Suite 310
Anchorage, AK 99501-6699
Get cash at over 855,000 ATMs* worldwide and get cash
back with purchases at many merchants like
Phone: (907) 269-6900
supermarkets.
Fax: (907) 269-6650
TTY: (907) 269-6894
*Regular ATM fees apply
TTY In-State Toll-Free 1-800-370-6894
Authorization Form
Custodial Parent's Name (please print)
First
Middle Initial
Last
Mailing Address
Street Address or PO Box
City
State
Zip
Daytime Phone
(
)
Social Security Number (required)
Date of Birth
/
/
Your Mother's Maiden Name (required)
By signing this form, I authorize the State of Alaska Child Support Services Division (CSSD) to share with
JPMorgan all of the information I provide on this form. CSSD will share this information with JPMorgan for the
purpose of establishing a Alaska Child Support Visa Debit Card account for me at JPMorgan and to process my
child support payments to JPMorgan. I authorize CSSD to deposit my child support payments to this account.
This action cancels and replaces any direct deposit agreement I currently have in place with CSSD. Upon
authorization of my account with JPMorgan, I agree to be bound by the Alaska Debit Card Disclosure Statement
and User Agreement that I will receive with my card.
Signature (required)
Date (required)
CSED 04-0006 (Rev 1/20/05)

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