(Cacfp) Direct Deposit Authorization Form printable pdf download

Proudly serving Mahoning, Medina, Portage, Stark, Summit & Trumbull counties

703 S. Main Street, Suite 211 * Akron, Ohio 44311 * 1-800-407-5437 * FAX 1-800-777-0655 *

Child and Adult Care Food Program (CACFP) Direct Deposit Authorization Form

Complete the Direct Deposit Authorization Form below to

Child Care Connection, a program of Info Line, Inc.

is pleased to offer to you a new convenience –

take advantage of the direct deposit service. The Direct

Deposit Authorization Form gives our Child Care

Direct Deposit. Now you can have your monthly CACFP

Connection, a program of Info Line Inc., the authority to

reimbursement check automatically deposited into your

deposit your CACFP reimbursement funds into your

checking or savings account.

account.

You do not have to change your present banking

relationship to take advantage of this service.

All you need to do is:

Direct Deposit is safe, convenient, easy, and will

1. Mark the box before type of account to indicate

help you in many ways.

whether your CACFP reimbursement will be

deposited to your checking or savings account.

It saves you trips to your financial institution.

It saves you time in depositing checks – no long

2. Fill in your name, the name and location of your

lines to wait in.

financial institution, today’s date, and sign your name.

It eliminates the possibility of lost, stolen or forged

3. Attach a voided check for verification of all financial

checks.

institution information. If you are unable to attach a

Your money is deposited faster-reduces the

voided check, please be sure to fill in your account

possibility of overdrafts.

number.

You get your money deposited into your account

4. Mail completed form to:

even if you’re on vacation

Child Care Connection

The amount of deposit will also appear on your bank

703 S. Main Street, Suite 211

statement.

Akron, OH 44311

ATTN: CACFP

TEAR ALONG PERFERATED LINE

CHILD CARE CONNECTION DIRECT DEPOSIT AUTHORIZATION FORM

Please complete the information below and return to Child Care Connection, 703 S. Main St., #211, Akron, OH 44311

I, _____________________________, authorize Child Care Connection, a program of Info Line, Inc. to initiate electronic credit entries

each month for CACFP reimbursement deposits and if necessary, debit entries and adjustments for any credit entries in error to my:

CHECKING ACCOUNT

( OR )

SAVINGS ACCOUNT

I acknowledge that the origin of Automated Clearing House (ACH) transactions to my account must comply with the provisions of

International Standards law. This authority will remain in effect until I have cancelled it in writing.

Financial Institution Name:

Date:

(PLEASE PRINT or TYPE)

Account No.:

Routing No.:

Financial Institution Address:

City:

State:

Signature:

Print/Type Your Name:

Supporting early care and education since 1990.

The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color,

national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual

orientation, or all part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any

program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.)

If you wish to file a Civil Rights program complaint of discrimination, complete the

USDA Program Discrimination Complaint Form

found online

at , or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter

containing all the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director,

Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at

program.intake@usda.gov