NON TITLE IV-D/SDU CASES ONLY
Please return completed form to:
Central Governmental Depository
P.O. BOX 698
Green Cove Springs, Florida 32043
STATE OF FLORIDA DISBURSEMENT UNIT
DIRECT DEPOSIT INFORMATION FORM
Name Date:
Case No.: SS#
Address
City County State Zip
Phone Number: Alternate Phone Number:
I have authorized the Central Governmental Depository/SDU to automatically deposit my child support payments at
(BANK NAME) (CITY, STATE)
Bank transit routing number:
To the account selected below:
(ONLY one (1) account can be selected for direct deposit of child support payments.)
Checking account number
(PLEASE ATTACH A PRE-PRINTED VOIDED CHECK OR LETTER ON LETTERHEAD FROM BANK WITH
ACCOUNT AND ROUTING NUMBERS)
Savings account number
(MUST HAVE A LETTER ON LETTERHEAD FROM BANK WITH ACCOUNT AND ROUTING NUMBERS)
I understand that the full amount collected will be deposited into the above selected account. I authorize the Bank to
accept the deposit for my account and to make adjustments to my account that corrects any error relating to the
deposit.
This authorization will remain in effect until revoked by me in writing or cancelled by the Bank. I understand that I
have the responsibility for discontinuing the deposits. I confirm that I have provided an ORIGINAL Pre-Printed
Voided Check/or a letter on letterhead from my Bank to verify and confirm my identity for my protection.
I agree that the Clay County Clerk’s Office will have no responsibility for personal checks written against my
account, and that my account will be administered in accordance with the rules and regulations of the Bank.
PETITIONER SIGNATURE
Sworn to or affirmed and subscribed before me on
By
Notary Public State of Florida
Personally known Seal
Produced identification
Type of identification produced
