Michigan > Local County > Genesee
Direct Deposit Authorization Form AT 2006-012 - Michigan
| Direct Deposit Authorization Form Form. This is a Michigan form and can be used in Genesee Local County . |
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Direct Deposit Authorization Form New Change Cancel (Check One Box Above and Complete the Balance of the Form in its Entirety) Your Name (Please Print): Last First Middle Phone Numbers: Home Phone Work Phone Other Phone Current Address: Number/Street/Apt# City State/Zip Country (if not US) Social Security Number: Case ID or Court Case (Docket) #: (Identify One Case Number, but Multiple Cases May be Paid in a Single Deposit.) Number County Bank Name: Bank Account Number: Checking Savings For a CHECKING account: Write VOID on an unused check and attach here John and Mary Jones 123 Main Street Anytown, MI 48888 Pay to: Bank Routing Number: 1234 $ For a SAVINGS account: Contact your bank. Obtain written verification of your account and routing numbers from your bank. Attach that verification to this form. VOID Anytown Bank Anytown, MI 48888 For: |: 072412345 |: 0012300456 " ' 1234 Routing Number (9 digits) Account Number (up to 17 digits) DOLLARS Do Not Complete Shaded Area I authorize the State of Michigan to deposit all support-related payments due me into the designated financial institution and account, and, if necessary, to initiate correcting entries, in case duplicates or other error transactions occur. I understand that the deposits will be made electronically, under the rules of the National Automated Clearing House Association (NACHA), and the State of Michigan. This authorization will remain in effect until cancelled by me with written notification to the state, or cancelled by the financial institution or the State of Michigan, at which time they will notify me by mail at the most current address they have on file for me. Sign Here: Mail this Form to: MiSDU Attn: Direct Deposit PO Box 30354 Lansing, MI 48909 7854 FAX: 517-318-4697 DATE: AT 2006-012 Attachment 5 American LegalNet, Inc. www.FormsWorkflow.com
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