Page 1 of 1 DIRECT DEPOSIT ENROLMENT/AUTHORIZATION FORM
CSF 08 0700A (10/01/16)
DIRECT DEPOSIT ~ OREGON ELECTRONIC DISTRIBUTION ENROLLMENT/AUTHORIZATION FORM
Send completed authorization to DOJ / DCS, P.O. Box 14320, Salem, OR 97309 OR Fax to (503) 986-2416
* Required Fields. Incomplete Authorizations may be returned to you causing a delay in your request.
PLEASE PRINT CLEARLY IN BLACK OR BLUE INK; Applications completed with red ink or pencil will be returned.
Please list all active CSP Case Number(s) you want deposited into this banking account:
________________________ ________________________ ________________________ ________________________
If you would like to include additional cases please write them on a separate piece of paper.
*Name: (The name that is currently on your support checks)_________________________________________________
LAST, FIRST MI
*Date of Birth (mm/dd/yyyy): _____/_____/_________Social Security Number:____________________
*Current Address Street Address (P.O. Box# / Apt. #), City, State, Zip Code, Country:
*Contact Phone #: ( )( )
Alternate Phone #:( )( )
BANK OR CREDIT UNION INFORMATION
*Name of Financial Institution (FI)_______________________________________________
*Checking
*Savings
FI Phone #:( )( ) *Name of Account Holder:__________________________
*Routing Transit Number: __ __ __ __ __ __ __ __ __ *Account Number:_________________________
ATTACH A VOIDED CHECK IDENTIFYING YOU AS A SIGNER ON THIS ACCOUNT
If you do not have checks you must attach a letter from your
Financial Institution, stamped/signed by them, on their
letterhead that identifies:
You as a signer on the account
Your routing number
Your complete account number
In lieu of a letter, your FI representative may sign, or teller
stamp, in this box verifying the bank information you have
provided above is complete and accurate
:
AUTHORIZATION: I certify I am entitled to the payments for the cases listed above. I authorize the Oregon Child Support Program
(CSP) to initiate credit entries of my child support payments, and if necessary debit entries for transactions made in error, into the
account above. I understand my payments will continue to be deposited in this account and this authorization will remain in full force and
effect, until the CSP receives written notification from me of termination or change of account or financial institution, at such time and in a
manner to provide a reasonable opportunity to act on it. To change financial institutions or accounts, I will complete and submit a new
Authorization form. By signing this form I authorize the named financial institution to assist the CSP in validating the account information
provided by me as related to the requirements of this application.
INTERNATIONAL TRANSACTION CERTIFICATION
I certify that the entire amount of my direct deposit payment IS NOT deposited to a financial institution outside the U.S. (NOTE: If
your entire net payment IS directed outside the U.S. contact the Oregon Child Support Program).
SIGNATURE: _____________________________________________ DATE: ____________________________
If we are not able to process this form with the information provided would you like us to continue
sending deposits to your account on record until a corrected application can be provided. (If neither
option is checked your deposits will be suspended until a valid and complete application can be processed)
YES, continue deposits NO, suspend deposits
If you have any questions about this form please contact (800) 850-0228 or visit the Oregon Child Support Program website at:
OregonChildSupport.gov
