JODY PHILLIPS
Duval County Clerk of the Circuit Court
Domestic
Relations Depository
Electronic Funds Transfer Program
501 West Adams Street
Jacksonville, FL 32202
Fax: 904-255-2392
Electronic Funds Transfer Program Authorization Form
Please complete this form and mail it to the above address if you wish your child support
payments to be deposited automatically to your bank. Please print.
Daytime Telephone:
You may have payments deposited to either (Check One):
Checking Account:
Savings Account
:
Date:
Signed:
This authorization will remain in effect until I send my written cancellation notice to the Duval County Domestic
Relations Depository. In no case can my cancellation be effective with respect to entries processed by the
Depository
prior to the receipt of my notification.
Obligees that receive support though the State of Florida Department of Revenue are not eligible for this program
through the Clerk's Office. Please contact the Department of Revenue or the Florida State Disbursement Unit for
further information.
Your Name:
Your SSN:
Home Address:
Date of Birth:
Name of person who pays child support to you:
Case No:
Please attach a voided check (not a temporary check) or letter from bank with
an account number and routing number.
Deposits will not begin for
at least ten days after this authorization form is received. Each deposit will be available in
your bank account approximately three days after the payment is released by the Depository. Please keep a copy
of
this form for your records.
I authorize the Duval County
Domestic Relations Depository to initiate deposits and to initiate, if necessary, debit
entries and adjustments for any credit entries in error to my account in the bank named above, and I authorize the
bank to perform these transactions.
Request to cancel Direct Deposit
New Request
Modifying Request
Please select one:
