Child Support Automatic Withdrawal Authorization Form - Missouri
EXAMPLE 1
CATHY SMITH 123
123 STREET
ANYTOWN, MO 65000 DATE___________
PAY TO T HE ORDE R OF _______________________________| $_______________
______________________________________________________________DOLLARS
MEMO_____________________ ___________________________
123456789 98765432111234 123
EXAMPLE 2
CATHY SMITH 123
123 STREET
ANYTOWN, MO 65000 DATE___________
PAY TO T HE ORDE R OF _________________________________| $_______________
______________________________________________________________DOLLARS
MEMO_____________________ ___________________________
123456789 123 98765432111234
SECTION C — W ITHDRAWAL AMOUNT AND FREQUENCY
Check one box in Section C to indicate how often you want support payments withdrawn from your bank
account. Enter the amount of each withdrawal and when withdrawals should occur.
SECTION D — I MPORTANT INFORMATION REGARDING WI THDRAWAL DATES
Carefully read the informat ion in Section D regarding withdrawal dates. If you do not want payments withdrawn
fr om your account as indicated in Sect ion D, do not complete the Aut om atic Withdr aw al Authorization.
SECTION E — AUTOMATIC WITHDRAWAL AUTHORIZATION
Carefully read the information included in Section E and sign and date the form to agree to the terms of the
automatic withdrawal. If you do not agree to the terms of the automatic withdrawal, do not complete the
Automatic Withdrawal Authorization. For joint accounts, the joint account holder must also sign and date the
form.
WHAT YOU SHOULD E XPECT
• Your automat ic payment authorization will be processed when it is received at the FSPC.
• The FSPC will send a “pre note” or test of your automatic withdrawal to your bank to ensure routing and
account numbers ar e acc ur at e.
• You will begin having payments withdrawn from your account once the pre note is complete. This should
be approximately five business days after the FSPC receives your application. The actual time will depend
on how often you request ed payment s be withdrawn fr om your account.
• During the time it takes to process the authorization and pre note the automatic withdrawal, you must
continue to make support payments by another m et hod.
• If your bank does not honor your withdrawal because of insufficient funds, a stop payment or a closed
account, the FSPC may term inate your autom atic withdrawal enrollment. Any resulting debt to t he FSPC is
subject to collection action.
CHANGING OR TERMINATING YOUR AUTOMATIC WITHDRAWAL AUTHORIZATION
Support payments will continue to be withdrawn from your desig nated account at your f inancial institution until
you notify the FSPC that you wish to terminate the withdrawals or change the financial institution and/or
account f r om which your payments are withdrawn. To c hange t he payment f req uency, payment dat e, payment
amount, financial institution, and/or account from which your support payments are withdrawn, you must
complete a new Automatic Withdrawal Authorization. To terminate your automatic withdrawal authorization
and/or to obtain an additional Automatic Withdrawal Authorization, contact the FSPC at 1–888–761–3665. It
will take approximately 30 days to process your termination request and/or your new Automatic Withdrawal
Authorization.
Routing
Number
Routing
Number
Account
Number
Account
Number
Check
Number
Check
Number
MO 886–3953 (8–14) CS–161 (Rev. 8–14)
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