Child Support Automatic Withdrawal Authorization Form - Missouri
STAT E OF MISSOURI
FAMILY SUPPORT PAYMENT CENTER
AUTOMATIC WITHDRAWAL AUTHORIZATIO N
INSTRUCTIONS
Child and/or spousal support payments that you pay to the Family Support Payment Center (FSPC) may be
automatically withdrawn f r om your bank account and paid t o t he FSPC. Car efully read the enclosed Frequently
Asked Questions About Automatic Withdrawal to learn more about this payment method before completing
this authorization. If you want your support payments automatically withdrawn from your bank account and
paid to the FSPC, complete the Automatic Withdrawal Authorization using the following instructions. If you
want support payments withdrawn f or more than one support order, you must complete a separate Automatic
Withdr awal Authorization for each order .
With t he exception of your sig natur e, type or pr int the r equest ed inf ormat ion. Retur n t he orig inal application to:
FAMILY SUPPORT PAYMENT CENTER, PO BOX 109006, JEFFERSON CITY, MO 65110–9006. Keep a
copy of the application and these instructions for your records. If you do not provide all the information
requested, the FSPC may not be able to process your authorization. If you need help completing the
Automatic Withdrawal Authorization, contact the FSPC between 8:00 a.m. and 5:00 p.m., Monday through
Friday at 1–888–761–3665. You may also write to the FSPC at the above address.
ORIGINAL OR CHANGED AUTHORIZATION
In the top r ight–hand corner of the form, c heck one box to indicate whether this aut hor ization is:
• An original automatic withdrawal authorization (you do not currently make support payments to the FSPC
by automatic withdrawal but are completing t his aut hor ization to do s o) ; or
• A request to change your existing automatic withdrawal authorization (you currently make support
payments to t he FSPC by autom atic withdrawal but want to change the payment f r eq uency, payment date,
payment amount, financial institut ion, and/ or ac count from which your payments are withdrawn).
SECTION A — PAYOR INFORMATION
1. Enter your name (if you are the person oblig at ed t o pay support ).
2. Enter your Social Security number.
3. Enter your home address .
4. Enter your e–mail a ddr es s if you wish to receive electronic payment confir m at ion not ices from t he FSPC.
5. Enter your telephone number , including t he area code. A daytime telephone number is pr eferred.
6. Enter your eight –dig it cas e num ber .
7. Enter your court or der number. If you want support payments withdrawn for more t han one support order ,
you must complete a separ at e Aut omatic Wit hdr aw al Aut hor ization for each order.
8. Enter the count y in which your support order was entered.
SECTION B — FINANCIAL INSTITUTION INFORMATION
You must attach a voided check or deposit slip to the authorization in the space indicated, or the
FSPC WILL NOT process your authorization.
1. Enter the com plet e nam e of the financial institution where you have your account.
2. Enter the financial institution’s telephone num ber , including t he area code.
3. Check the box that describes the type of acc ount from which you want support payments withdrawn.
4. Enter your financial institution’s nine–digit routing number. The routing number is printed on the bottom
left–hand portion of your checks and deposit slips ( see Examples 1 and 2 on reverse side) .
5. Enter your deposit or account number. If your account is a checking account, the account number is
printed on the bottom of your personal checks following your routing number. It may be the first series of
digits after the routing num ber (see Example 1 on reverse side), or it m ay be the ser ies of digits t hat follow
your check number (see Example 2 on reverse side). Do not include your check number in the account
number.
NOTE
: Enter only numbers for your routing and account numbers. Sometimes there are special symbols
before or after the routing and account numbers on your check. Those special symbols should not
be included.
MO 886–3953 (8–14) (OVER) CS–161 (Rev. 8–14)
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