Child Support Automatic Withdrawal Authorization Form - Missouri
STAT E OF MISSOURI
FAMILY SUPPORT PAYMENT CENTER
This is an original authorization
AUTOMATIC WITHDRAWAL AUTHORIZ ATION
This is a change to an existing authorization
SECTION A — PAYOR INFORMATION
NAME (LAST, FIRST, MIDDLE)
SOCIAL SECURITY NUMBER
ADDRESS (PO BOX OR STREET ADDRESS) (APT NUMBER)
(CITY) (STATE) (ZIP CODE)
E–MAIL ADDRESS (PROVIDE IF YOU WISH TO RECEI VE ELECTRONIC PAYMENT CONFIRMATION NOTICES)
TELEPHONE NUMBER (INCLUDING AREA CODE)
CASE NUM BER (EIGHT DIGITS)
COURT ORDER NUMBER
COUNTY OF ORDER
SECTION B — FINANCIAL INSTITUTION INFORMATION (VOIDED CHECK OR DEPOSIT SLIP MUST BE ATTACHED)
FINANCIAL INSTITUTION NAME
TELEPHONE NUMBER (INCLUDING AREA CODE)
STAPLE VOIDED
CHECK OR
DEPOSIT SLIP
HERE
TYPE OF ACCOUNT (CHECK ONE BOX)
CHECKING
SAVINGS
ROUTING NUMBER (9 DIGITS)
ACCOUNT NUMBER
SECTION C — WITHDRAWAL AMOUNT AND FREQUENCY (INDICATE ONE OF THE FOLLOWING OPTIONS)
WITHDRAW MY PAYMENT ONCE A MONTH
AMOUNT OF WITHDRAWAL DATE OF WITHDRAWAL
WITHDRAW MY PAYMENT TWICE A MONTH
AMOUNT OF EACH WITHDRAWAL DATES OF WITHDRAWAL
1ST 2ND
WITHDRAW MY PAYMENT EVERY TW O WEEKS
AMOUNT OF EACH WITHDRAWAL
DAY OF WITHDRAWAL (FOR EXAMPLE, MONDAY)
WITHDRAW MY PAYMENT ONCE A WEEK
AMOUNT OF EACH WITHDRAWAL
DAY OF WITHDRAWAL (FOR EXAMPLE, MONDAY)
SECTION D – IMPORTANT INFORMATION REGARDING WITHDRAWAL DATES (PLEASE READ CAREFULLY)
• If a withdrawal date falls on a Saturday, Sunday or banking holiday, the Family Support Payment Center (FSPC) will
withdraw the payment on the following banking business day.
• If a withdrawal date f alls on the last day of the m onth and t hat day is a Saturday, Sunday or banking holiday, the FSPC will
deduct the payment on the last banking business day of the month.
• If a withdrawal date does not occur in each month (for example, the 31st), the FSPC will deduct the payment on the last
banking business day of the month during months in which that date does not occur.
• Twice–monthly withdrawals must be based on one of the following schedules: 1st
and 16th; 2nd and 17th; 3rd and 18th;
4th and 19th; 5th and 20th; 6th and 21st; 7th and 22nd; 8th and 23rd; 9th and 24th; 10th and 25th; 11th and 26th; 12th and
27th; 13th and 28th; 14th and 29th; or 15th and 30th.
•
The FSPC will apply the payment to your support order on the day it is withdraw n from your account.
SECTION E — AUTOMATIC WITHDRA WAL AUTHORIZATION
I hereby authorize the above withdrawals from my account for payment to the FSPC. I understand this authorization does
not exem pt me f rom any enforcem ent actions allowable under st ate and federal law. I understand the FSPC m ay terminate
my automatic withdrawal enrollment if my financial institution does not honor my withdrawal authorization because of
insufficient funds, a stop payment or a closed account. Any resulting debt to the FSPC is subject to collection action.
ACCOUNT HOLDER’S SIGNATURE
DATE SIGNED
SECOND ACCOUNT HOLDER’S SIGNATURE (REQUIRED FOR JOINT ACCOUNTS)
DATE SIGNED
SECTION F — FOR FSPC USE ONLY
MEMBER NUMBER
DATE AUTHORIZATION RECEIVED
DATE WITHDRAWALS WILL START
MO 886–3953 (8–14) CS–161 (Rev. 8–14)
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