Direct Deposit Form
Instructions to set up Direct Deposit for both Checking and Savings accounts:
Checking: (2 options)
• Option A. If including a VOIDED, PRE-PRINTED CHECK: Complete Section 1; complete Section 2 except for
Representative's name and signature, and include a VOIDED, PRE-PRINTED CHECK (no starter checks), or other
bank document with your name and account information pre-printed by the bank.
• Option B. If not including a VOIDED, PRE-PRINTED CHECK: Complete Section 1 then take or fax this form to
your bank and have a representative of the bank complete and sign Section 2
Savings: Complete Section 1, and Section 2 except for Representative's Name and Signature.
**Once you have completed this form please submit using the contact information at the bottom of this form.**
**Please be advised that once we receive and process this form, it will take 10 days to be effective**
Section 1 PLEASE USE BLACK INK SSN
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I authorize the KPC to make deposits to the account listed
below. The KPC may make deposits to this account until I
cancel the authorization and the KPC has time to process the
cancellation. If funds are mistakenly deposited into my account,
I authorize the KPC to deduct the amount of the error from my
account.
Section 2 To be filled out by Bank Representative
I confirm the identity of the above-named payee and the below
listed account number and routing number and to be in the correct
format to properly post to the account. As a representative of this
financial institution, I certify that the financial institution agrees to
receive and deposit the payment from the KPC.
CHECKING SAVINGS
ROUTING #
ACCOUNT #
Note: This section is only used if you are changing from one bank account to another. If this box is not checked, your previous bank account will
remain active until the new Direct Deposit takes effect (10 days). If you choose to end all direct deposit instructions, visit kspaycenter.com for the
KPC KEY2Benefits debit card enrollment and pre-authorization forms prior to when the next payment is disbursed to you.
Kansas Payment Center
PO Box 750080
Topeka, KS 66675-0080
785-232-7533
877-572-5722
The Kansas Payment Center is funded by the Kansas Department for Children and Families
NAME, ADDRESS, & PHONE NUMBER OF FINANCIAL INSTITUTION
YOUR NAME (last, first, middle initial)
ADDRESS (Street, Route, P.O. Box)
PLEASE CIRCLE ONE
HOME WORK CELL
PRINT OR TYPE REPRESENTATIVE'S NAME
SIGNATURE OF REPRESENTATIVE
I request my previous Direct Deposit account be cancelled immediately.
