Fillable STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES (California)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES (California)

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  • 5 check-boxes
  • 13 other fields

Country of origin: US
File type: PDF

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
IN-HOME SUPPORTIVE SERVICES PROVIDER DIRECT DEPOSIT
ENROLLMENT/CHANGE/CANCELLATION FORM
Check Appropriate Box:
■■ NEW By checking this box, I hereby authorize the State Controller’s Office to directly deposit my pay warrants
to my personal bank account.
■■ CHANGE By checking this box, I hereby authorize the State Controller’s Office to change my Direct Deposit to my
new personal bank account.
■■ CANCEL By checking this box, I hereby cancel my Direct Deposit authorization.
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CASE NUMBER: PROVIDER NUMBER:
TYPE OF ACCOUNT: ■■ CHECKING ■■ SAVINGS
(Check only one type)
ROUTING NUMBER:
(MUST BE 9 NUMBERS)
ACCOUNT #:
BANK NAME:
SIGNATURE OF PAYEE
(PROVIDER)
By signing you acknowledge that you will not send 100% of funds deposited to your bank to another bank outside the US.
NAME OF PROVIDER FIRST MIDDLE INITIAL LAST
STREET CITY STATE ZIP CODE
SOC 829 (9/12)
DATE
IN-HOME SUPPORTIVE SERVICES
PROVIDER DIRECT DEPOSIT ENROLLMENT INSTRUCTIONS
You are not eligible for Direct Deposit if you are planning to send 100% of funds deposited to your bank to another bank
outside the US.
You will need the following information to complete the Direct Deposit Enrollment Form:
1. The name of your Bank.
2. The Bank Routing Number
3. Your Checking or Savings Account Number. If you need help identifying this information please ask your Bank
for assistance.
CHECK APPROPRIATE BOX
Please check the box to tell us what you want to do. Check the Box: NEW to enroll in direct deposit; CHANGE to change
your bank account; and CANCEL to cancel direct deposit.
Check the box to tell us whether you want your paycheck deposited in your Checking or Savings account.
IDENTIFICATION INFORMATION
Provide your Case and Provider number. You will find the case and provider numbers on your IHSS Statement of
Earnings (pay stub).
BANKING INFORMATION
Provide the information requested on the form. You may find the bank information you will need to complete the enrollment
form on your personal checks or your bank may assist you. Below is an example of a check and where to find the
necessary information.
Check Example:
Your Name Check NO. 4444
Pay to the Order of _________________________________
I112145678 I: 5765432109812 4444
Routing No. Your Acct. No. Ck. No.
If you prefer to have your money deposited into your savings account, please contact your bank for assistance.
PROVIDE ALL REQUESTED INFORMATION
All information requested on the form must be provided. Incomplete forms will be returned. To enroll in Direct Deposit you
must complete all fields on an Enrollment/Change/Cancellation form. Your signature authorizing Direct Deposit must be an
ORIGINAL SIGNATURE, photocopies will not be accepted.
IF YOU WORK FOR MULTIPLE RECIPIENTS
You must complete a separate Provider Enrollment/Change/Cancellation form for EACH Recipient with whom you are
employed. When you begin work for a new recipient you will need to complete a new form.
CHANGING OR CANCELLING YOUR DIRECT DEPOSIT
Your Direct Deposit will continue to be deposited into the bank account you have chosen until you request a change. If you
wish to change or cancel your Direct Deposit authorization for any recipient for whom you work, you must submit an
Enrollment/Change/Cancellation form with a check next to the box for Change or Cancel. You may access our website at
www.dss.cahwnet.gov to download additional forms or contact the Direct Deposit Help desk toll free at (866) 376-7066.
Please send your COMPLETED Enrollment/Change/Cancellation Form to:
PROVIDER ENROLLMENT PROCESSING CENTER
P.O. BOX 1120
ROSEVILLE, CA 95678
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SOC 829 (9/12)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES (California)

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Completed 7 June 2021

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