Form Esa-1126a - Cancellation Of Direct Deposit

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ARIZONA DEPARTMENT OF ECONOMIC SECURITY
ESA-1126A FORFFA (11-17)
Unemployment Insurance Program
CANCELLATION OF DIRECT DEPOSIT
Use this form to cancel payment of your current Unemployment Insurance benefits to your direct deposit
account. Once cancelled, the remainder of your Unemployment Insurance benefits will be sent in the
same manner you received payment prior to direct deposit. Please complete the requested information
and mail completed form to the address below.
NAME (Last, First, M.I.)
SOCIAL SECURITY NUMBER
CURRENT ADDRESS (No, Street, Apt. No.)
CITY
STATE
ZIP CODE
DIRECT DEPOSIT
I authorize the Arizona Department of Economic Security, Unemployment Insurance Program
to terminate any future payments of my Unemployment Insurance benefits to my direct deposit
account.
SIGNATURE
DATE
MAIL COMPLETED FORMS TO:
Arizona Department of Economic Security
Unemployment Insurance Program
P.O. Box 6666
Phoenix, AZ 85005-6666
This address is to be used ONLY for mailing the Direct Deposit form. Other correspondence or
materials mailed to this office may result in a delay to the intended recipient.
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with
Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic
Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities,
or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department must make a
reasonable accommodation to allow a person with a disability to take part in a program, service, or activity. Auxiliary aids and services
are available upon request to individuals with disabilities. To request this document in alternative format or for further information about
this policy, Contact your local office; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request. •
Disponible en español en línea o en la oficina local.

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