Alaska > Statewide > Child Support Services Division
CSSD Check Reissue Request 04-1013 - Alaska
| CSSD Check Reissue Request Form. This is a Alaska form and can be used in Child Support Services Division Statewide . |
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Alaska Department of Revenue Please Reply To: CSSD, MS 12 550 W. 7th Ave., Suite 310 Anchorage, AK 99501-6699 www.childsupport.alaska.gov Child Support Services Division CSSD Check Reissue Request Date of Request: Name: Address: If New Address: Case Number: Check number: Amount of Check: Date Issued: Check number: Amount of Check: Date Issued: Please issue a Stop Pay on the above noted check(s) for the following reason: Never Received Lost Stolen Other I agree not to cash this/these check(s) if received and will return it/them to the Child Support Services Division. If I cash this/these checks I am giving CSSD permission to automatically recover these amounts from Future Monthly Support Obligations. Signature Printed Name Date received in SDU CSSD 04-1013 (Rev: 06/13/11) Date request completed MAT-SU: ( 907) 357-3550 TOLL FREE (In-state, outside Anchorage): (800) 478-3300 SOUTHEAST: (907) 465-5887 ANCHORAGE: (907) 269-6900 FAX: (907) 787-3322 FAIRBANKS: (907) 451-2830 TDD machine only: (907) 269-6894 / TDD machine only, toll free (In-state, outside Anchorage): (800) 370-6894 American LegalNet, Inc. www.FormsWorkFlow.com Authorization Form for Visa Debit Card or Direct Deposit to Bank Account Please check one: Custodial Parent's Name (please print) CSSD member ID # _______________* New Change or Cancel First Middle Initial Last *This is the 8 digit Member Number assigned to you by CSSD, not your 9 digit case number. Mailing Address Street Address or PO Box Daytime Phone City State Zip Social Security Number** (required for debit card) Your Mother's Maiden Name Date of Birth / / (required for debit card) **The disclosure of your social security number for direct deposit is voluntary. We will use your social security number to assist in the identification of your bank and financial account. ( ) Please choose only one of the below options for electronic deposit of your child support payments. -------------------------------------------------------------------------------------------------------------------------------------OPTION 1: Alaska Visa Debit Card please check the box if you would like to receive your child support payments this way and complete the information below. By signing this form, I authorize the State of Alaska Child Support Services Division (CSSD) to share with JPMorgan all of the information I provide on this form. CSSD will share this information with JPMorgan for the purpose of establishing an Alaska Child Support Visa Debit Card account for me at JPMorgan and to process my child support payment to JPMorgan. I authorize CSSD to deposit my child support payments to this account. Upon authorization of my account with JPMorgan, I agree to be bound by the Alaska Debit Card Disclosure Statement and User Agreement that I will receive with my card. Signature (required) Date (required) Regular ATM fees may apply. If you choose this option, see Alaska Debit Card Disclosure Statement and User Agreement when you receive the card. OPTION 2: Direct Deposit into your checking, savings or other bank account please check the box if you would like to receive your child support payments this way and complete the information below. In order to have your child support payment electronically deposited into your bank account you MUST attach a preprinted voided check or deposit slip to this form. This will be used to verify the name, bank routing number, and account number. I authorize the State of Alaska CSSD to make Direct Deposits to the account shown below (please note that the name on the bank account MUST match the name on the CSSD case). Name of bank or financial institution: Account Type CHECKING SAVINGS OTHER I authorize the State of Alaska CSSD to make necessary adjustments to the above account to correct any credit entries made in error. I understand that the CSSD will make a reasonable effort to notify me within 24 hours when an adjustment is made. This authority remains in effect as long as I have an open child support case with the State of Alaska CSSD. I understand that 30 days written notice is required to change financial institutions, account numbers, or account type and that I must notify CSSD if I close my account or change my mailing address. PLEASE REMEMBER TO ATTACH A PREPRINTED VOIDED CHECK OR DEPOSIT SLIP. Signature (required) Date (required) Daytime Phone (required) American LegalNet, Inc. www.FormsWorkFlow.com CSSD 04-0008 (Rev. 9/8/11)
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