Louisiana Direct Deposit Form 2 - Free Download
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Louisiana Direct Deposit Form 2
Louisiana Direct Deposit Form 2
OFS DD 2
Rev. 12/10
06/10 Issue Obsolete
Louisiana Department of Children and Family Services
Child Care Assistance Program
DIRECT DEPOSIT AUTHORIZATION FORM
Return to:
Provider Directory
P.O. Box 94065
Baton Rouge, LA 70804
Please TYPE or Legibly PRINT all information in INK.
Section 1: PARTICIPANT CASE INFORMATION
Name: Date of Birth:
Mailing Address:
City/State/ZIP:
Daytime Telephone #: ( ) Home Telephone #: ( )
Social Security Number: Provider Number:
Section 2: FINANCIAL INSTITUTION INFORMATION
Name of Financial Institution:
Mailing Address:
City/State/ZIP:
Telephone #: ( )
Routing Number: Account Number:
Account Type (Check One): Checking* Savings*
Check One: New Request Change Account Cancel Direct Deposit
*Note: Be sure to include a voided check for checking accounts. For savings accounts, submit a statement from your financial
institution showing the account number and routing number.
Section 3: AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT OF PAYMENTS
I authorize the Department of Children and Family Services (DCFS) to deposit my payments directly into
my checking account or savings account as specified above. DCFS is also authorized to adjust any
over/under deposit it has made to my checking account or savings account. I understand the
deposits/adjustments will be made electronically by Automated Clearing House Network (ACH)
transactions and I must allow the Federal Reserve two work days 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 for a
checking account or a statement from my financial institution showing the account number and the
routing number for a savings account. The voided check must be imprinted with my name and address. If
my voided check does not include this information, a statement from my financial institution showing my
name, address, account number and routing number must be provided. I will immediately notify DCFS if
my banking information changes. I must submit a new Direct Deposit Authorization form to change or
cancel my direct deposit. I must notify DCFS of any changes to my address. I must include my name and
provider number on all correspondence regarding direct deposit. To verify when a payment is posted to
my account and funds are available, I will have to contact my financial institution.
By signing below I signify that I have read and agree to all of the conditions listed above.
Signature: Date Signed:
Office Use Only
Date Entered: Entered By:
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