Form Dhs-1377 - Direct Deposit Authorization Form
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1Direct Deposit Authorization Form
Michigan State Disbursement Unit
Michigan Department of Human Services
New
Change
Cancel
(Check one box above and complete the entire form.)
Your Name (please print):
Last
First
Middle
Phone Numbers:
Home Phone
Work Phone
Other Phone
Current Address:
Number/Street/Apt. Number
City
State/ZIP
Country (if not U.S.)
Social Security Number:
Case ID or Court Case (Docket) Number:
(Identify one case number, but multiple cases may be paid in a
single deposit.)
Number
County
Bank Name:
Bank Routing Number:
Bank Account Number:
Checking
Savings
1234
For a CHECKING account:
John and Mary Jones
Write VOID on an unused
123 Main Street
Anytown, MI 48888
check and attach here.
Pay to:
$
For a SAVINGS account:
VOID
Contact your bank and
DOLLARS
Anytown Bank
obtain written verification
Anytown, MI 48888
of your account and
routing numbers. Attach
For:
Do Not Complete Shaded Area
that verification to this
|: 072412345 |: 0012300456 ” ’ 1234
form.
Routing Number
Account Number
(9 digits)
(up to 17 digits)
I authorize the State of Michigan to deposit all support payments with the designated financial institution and
account, and to initiate correcting entries, if necessary. I understand that the deposits will be made electronically
under the rules of the National Automated Clearing House Association (NACHA) and the State of Michigan. This
authorization will remain in effect until cancelled by me with written notification to the state, or cancelled by the
financial institution or the State of Michigan, at which time they will notify me by mail at the most current address
they have on file for me.
Sign Here:
Date:
Mail or fax this form to:
MiSDU
Attn: Direct Deposit
P.O. Box 30354
Lansing, MI 48909-7854
FAX: 517-318-4697
Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age,
Legal Authorities: 45 CFR
national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs
307.10
or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited
Completion: Voluntary
to make your needs known to a DHS office in your area.
DHS-1377 (06/09) MS Word
AT 2009-008 Attachment 6
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