Division Of Child Support Services printable pdf download

Nathan Deal, Governor

Robyn Crittenden, Commissioner

Georgia Department of Human Services ▪ Division of Child Support Services ▪ Tanguler Gray, Director

Two Peachtree Street, NW ▪ 20

Floor ▪ Atlanta, GA 30303 ▪ 404-657-3851 ▪ 404-657-3326 (Fax)

DIVISION OF CHILD SUPPORT SERVICES

To have child support sent directly to your checking account, please read, complete and print this form. Include a

voided check with your form. Mail both the voided check and this form to your local Child Support Services office.

Note: Child Support can direct deposit to checking or savings accounts.

Section 1:

Authorization Agreement for Direct Deposit of Child Support Payments

I authorize the Division of Child Support Services (DCSS) to deposit my child support payments directly into my checking or

savings account. DCSS is also authorized to adjust any over/under deposit it has made to my checking or savings

account. I understand the deposits/adjustments will be made electronically by ACH transactions and I must allow the Federal

Reserve two workdays from the disbursement date to have the funds available to my financial institution. I also understand the

following: It is my responsibility to provide correct Routing and Account information for ACH transmissions by attaching a

voided check or financial institution printout to this authorization. DCSS does no pre-note to verify my information. I will

immediately notify DCSS if my banking information changes. I must submit a new Authorization Form to change my direct

deposit. I can stop my direct deposit by notifying the DCSS Communications Center or local office. I must notify the DCSS

local office of any changes to my address. I must include my name and case number on all correspondence regarding direct

deposit. The DCSS Communications Center and web site provide the date the DCSS system disbursed my payment; I must

verify with my financial institution when the payment is posted to my account and funds are available for withdrawal.

By Signing below I signify that I have read and agree to all of the conditions listed above.

Signature:__________________________________________ Date Signed: _____/_____/________

**PLEASE TYPE OR LEGIBLY PRINT ALL INFORMATION BELOW IN INK**

Section 2:

CUSTODIAL PARENT INFORMATION

Name:

GA DCSS Case Number:

(As it appears on your GA DCSS check)

Social Security Number:

Additional GA DCSS Case Numbers:

Mailing Address:

City:

State:

Zip:

Daytime Telephone:

Email:

Section 3:

FINANCIAL INSTITUTION INFORMATION

Name of financial institution:

Routing Number

Account Number

Account Type:

[ ] Checking Account [ ] Savings Account

City:

State:

Telephone #:

Section 4:

For DCSS use ONLY

Date received:

Date input:

Initials:

Date verified:

Initials:

Please verify all information. Then, mail this completed form and a voided check / financial institution printout to the local DCSS

office. Check here if this is a Bank Card only account [ ]

Revised September 11, 2015

Division Of Child Support Services

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