Child Support Direct Deposit Authorization Form - Texas
November 2014 Form 6A002e
TEXAS CHILD SUPPORT DIRECT DEPOSIT
Authorization Form
Please attach a Voided Check or Letter from Financial Institution and Sign the bottom of this form prior to Mailing Back to:
TXCSDU, P.O. Box 659400, San Antonio, TX 78265
Please P rint or Type
1. Direct Deposit Action Requested: (Chec k One)
Attac h V oided Chec k or D e posit Slip Here
Start Change Stop
For accuracy please verify information with your financial institution for
ite ms 2-5
2. Account Type: (Check One)
Checking
Savings
3. Account Number:
4. Transit Routing Number: (9 Digits)
Please co ntact your financial insti tution for this numbe r
5. Name of Financial Institution:
Mailing Address:
Telephone:
6. Name of Payee: (last, first, mid dle) Custodial Parent
7. Name of Payor: (last, first, middle ) Non-Custodial Pa r e nt
8. County assigned Cause Number (see Court order):
9. Payee Address: (Number and Stre e t) City, State and Zip Code
10. Payee Telephone Numbers:
Work:
Home:
11. Payee Social Security Number: (Custodial Parent)
-
-
12. Signature: (Custodial P a r e nt)
Date:
Signature above signifies agreement with terms and conditions below.
By signing this authorization form, I consent to the policy of the Office of the Attorney General (OAG) for recovering money sent to me in error. Money
sent to me in error, NOT repaid within 30 days of notice of overpayment, will be withheld from future child support payments.
I authorize the financial institution to accept the deposit for my account and to make adjustments to my account to correct any error relating to
the
deposit.
I agree and understand that this authorization for direct deposit revokes OAG form 1A004, Authorization for Release of Information with
respect to redirection
of
child support payments.
This authorization form will remain in effect until revoked by me in writing or canceled by the financial institution and supersedes any
existing
instructions
concerning
my child support direct deposit. I also understand that I have a
responsibility
to provide a written request to
discontinue
the deposit. To discontinue direct deposit and provide a mailing address for future payments I must call 1-800-252-8014 to request
an authorization form. The authorization form should
be
returned to the TXCSDU, P. O. Box 659400, San Antonio, TX
78265.
I agree that the TXCSDU will have no
responsibility
for personal checks written against my account prior to the funds being available in my
account, and my account will be administered in accordance with the rules and regulations of the financial
institution.
WARNING: This is a governmental document. Texas Penal Code, Section 37.10 specifies penalties for making false entries or providing false
information in
the document.
Page 2/2
Free Download
Child Support Direct Deposit Authorization Form - Texas PDF
Favor this template? Just fancy it by voting!
(0 Votes)
0.0
Related Forms
61 Page(s) | 12120 Views | 36 Downloads
