Authorization: Direct Deposit (Obligee Accounts Only)
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1RETURN YOUR SIGNED AUTHORIZATION
by Fax to: 303-299-9122 or by Mail to: FSR P.O. Box 2171 Denver, CO 80201-2171
DO NOT EMAIL unless you have the ability to send via secure email.
AUTHORIZATION: DIRECT DEPOSIT (OBLIGEE ACCOUNTS ONLY)
NEW
CHANGE REQUEST
CANCEL
PERSONAL:
Name (Please Print):
Last
First
Middle
Address:
Street
Apt. No.
City
State
Zip
Daytime Telephone: (
)
-
Home Telephone: (
)
-
FSR Account Number(s)(Required):
Note: If you have multiple FSR accounts, provide all of the account numbers. Your authorization will apply to all
of your FSR accounts.
:
Social Security Number
Note: Provision of your Social Security Number is voluntary. However, if you fail to provide your Social Security
Number, we will not be able to process your request. Social Security Numbers are used by the Division of Child
Support Enforcement to locate individuals for the purposes of establishing paternity, establishing support
obligations, modifying and enforcing child support obligations and distribution of child support payments.
BANK:
Bank Name:
Branch Location:
Checking
Savings
Account Type (Check One):
Bank Routing Number:
Bank Account Number:
EXAMPLE:
Your bank routing number is identified by the symbols
before and after the number at the bottom of the check.
Your bank account number is identified by the symbol
after the number at the bottom of the check
If you do not have a voided check
or this is a savings account, have
a bank representative complete
the above bank information.
I understand this form authorizes the Family Support Registry to initiate credits and correcting debits to
the above account. A debit (withdrawal) to this account will only occur if a credit (deposit) is originated in
error. I will receive notification if a debit to my account occurs.
I understand that any request for changes to this authorization must be received at least three (3)
business days before the next payment is scheduled to be disbursed to your bank account.
I understand that the availability of funds is dependent on the posting schedule of my bank and it is my
responsibility to verify availability.
SIGNATURE:
DATE:
FSR
P.O. Box 2171·Denver, CO· 80201-2171
Metro Denver 303-299-9123 · Nationwide 1-800-374-6558
Revised 2/29/2012
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