Arizona > Local County > Maricopa > Superior Court > Family Law
Electronic Payment Authorization 405 - Arizona
| Electronic Payment Authorization Form. This is a Arizona form and can be used in Family Law Superior Court Maricopa Local County . |
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CSE-1129AFORPF (10-05) ARIZONA DEPARTMENT OF ECONOMIC SECURITY Division of Child Support Enforcement Arizona State Disbursement Unit ELECTRONIC PAYMENT AUTHORIZATION Check applicable box(s): New Direct Deposit Authorization New Electronic Payment Card Changes to Account Information Only If you fail to provide all the information requested on this form, your request will not be processed and this form will be returned to you. IV-D case (If you receive or have received cash assistance in the past, and/or have applied for IV-D services, or if you have an open case with DCSE, then your case is considered a IV-D case.) Non IV-D case (ALL NON-DCSE IV-D cases where only the local court is involved) COURT ORDER NUMBER NAME (Last, First, M.I.) CURRENT MAILING ADDRESS (No., Street, P.O. Box, City, State, Zip) ATLAS CASE NUMBER SOCIAL SECURITY NUMBER CONTACT'S TELEPHONE NUMBER ( ) CUSTODIAL PARENT'S DATE OF BIRTH (MM/DD/YYYY) I hereby authorize the Arizona State Disbursement Unit (SDU) or its agent designated to initiate credit entries and, if Checking, Savings Account necessary, debit entries and adjustments for any credit entries made in error to my (our ) indicated below, to credit and/or debit the same to such account for the purpose of support payments. DIRECT DEPOSIT ONLY IMPORTANT! Please attach a copy of a voided check from your account or a letter from your financial institution if a check is not available. ACCOUNT NUMBER FINANCIAL INSTITUTION'S NAME 2nd NAME ON ACCOUNT (Last, First, M.I.) BANK ROUTING NUMBER 1ST NAME ON ACCOUNT (Last, First, M.I.) All of your child support payments and, if applicable, spousal maintenance will go through direct deposit. They will be deposited into one account only, which can be a savings or checking account. If you wish funds to be deposited to your checking account, please must attach a personal check marked "VOID" and complete the following information. If you wish funds to be deposited to your savings account, please provide a letter from your financial institution with your routing and account number. This authority is to remain in full force and effect until DCSE has received written notification from me of its termination in such time and in such manner as to afford DCSE a reasonable opportunity to act on the notice. This authority may also be terminated by DCSE or its agent by mailing notice to the last mailing address I provided to DCSE or its agent. I will keep the Arizona State Disbursement Unit (SDU) or its agent informed of any address change that may occur. I understand that failure to do so will result in undelivered support payments. Please sign and mail or fax the completed form to your local Clerk of Court Office or the Arizona State Disbursement Unit (SDU), as appropriate. Attached is a listing of local Clerks of Court and/or Arizona State Disbursement Unit (SDU). PRINT YOUR NAME YOUR SIGNATURE FOR OFFICAL USE ONLY: DATE IV-D case Non IV-D case Equal Opportunity Employer/Program Form #405 LRD 6-1-06 ALL RIGHTS RESERVED ©Clerk of the Superior Court of Arizona in Maricopa County American LegalNet, Inc. www.FormsWorkflow.com AUTHORIZATION FORM SUBMITTAL LOCATIONS All IV-D Cases ARIZONA STATE DISBURSEMENT UNIT (SDU) Electronic Payment Authorization Unit P.O. Box 36626 Phoenix, AZ 85067-6626 Phone: (602) 252-4045 FAX: (602) 274-8327 All non-IV-D Cases Apache Clerk of Court P.O. Box 365 St. Johns, AZ 85936 Phone: (928) 337-7550 Graham Clerk of Court 800 Main Street-Courthouse Safford, AZ 85546 Phone: (928) 428-3100 Mohave Clerk of Court P.O. Box 7000 Kingman, AZ 86402-7000 Phone: (928) 753-0713 Ext. 4213 Navajo Clerk of Court P.O. Box 668 Holbrook, AZ 86025 Phone: (928) 524-4186 Pima Clerk of Court 110 W. Congress, 1st Floor Tucson, AZ 85701 Phone: (520) 740-3250 Pinal Clerk of Court P.O. Box 2730 Florence, AZ 85232 Phone: (520) 868-6309 Santa Cruz Clerk of Court P.O. Box 1265 Nogales, AZ 85628 Phone: (520) 375-7701 Cochise Clerk of Court P.O. Drawer CK Bisbee, AZ 85603 Phone: (520) 432-8600 Coconino Clerk of Court 200 North San Francisco St. Flagstaff, AZ 86001 Phone: (928) 779-6541 Gila Clerk of Court 1400 E. Ash Street Globe, AZ 85501 Phone: (928) 425-3231 Ext. 8556 Greenlee Clerk of Court P.O. Box 1027 Clifton, AZ 85533 Phone: (928) 865-4242 La Paz Clerk of Court 1316 Kofa Ave, Suite 607 Parker, AZ 85344 Phone: (928) 669-6131 Maricopa Clerk of Court 201 W. Jefferson Phoenix, AZ 85003 Phone: (602) 506-8868 Yavapai Clerk of Court 120 South Cortez Prescott, AZ 86303 Phone: (928) 771-3312 Yuma Clerk of Court 250 W. Second St., Suite B Yuma, AZ 85364 Phone: (928) 329-2164 Form #405 LRD 6-1-06 ALL RIGHTS RESERVED ©Clerk of the Superior Court of Arizona in Maricopa County American LegalNet, Inc. www.FormsWorkflow.com
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