Form Ldss 5025 – Fill Out and Use This PDF

LDSS-5025 (Rev. 7/15)

NYS OTDA State Supplement Program (SSP)

Direct Deposit Enrollment Form

Directions:

∙To be completed by individuals who receive only SSP benefits. Individuals receiving federal SSI benefits need to contact SSA.

∙Complete this form ONLY if you wish to enroll in Direct Deposit. BOTH sections must be completed.

∙Return the completed form to: NYS OTDA State Supplement Program, PO Box 1740, Albany NY 12201; or

by FAX to: 518-486-3459; or Email the hand signed form to otda.sm.ssp@otda.ny.gov

∙Please contact the SSP Customer Support Center at 1-855-488-0541 with any questions.

The following information must be provided. If ANY information is missing, the form will be returned for completion.

Recipient Name ___________________________________________			Daytime Phone Number (____) _______-________
LAST	FIRST	MI
Recipient Mailing Address __________________________________________________________
City ____________________________________________			State ____________ Zip Code _________
Date of Birth (MM/DD/YYYY) ____ / ____ / ________		Last Four Numbers of SSN XXX -XX-_______________

I certify that I am entitled to the benefits associated with the NY State Supplement Program (SSP). In signing this form, I authorize the SSP to send my benefits to the financial institution named below to be deposited into the account indicated by the financial institution. This authorization will remain in force until I provide written notice of termination.

Print Name_________________________________ Signature __________________________________ Date ____________

ACCOUNT INFORMATION

Please take this form to your bank or credit union for the completion of the information below. You may also choose to attach a voided preprinted (not starter) check containing your name and address or an account deposit form containing your name and address.

This CANNOT be a Trust Account to benefit another OR a Foreign Financial Institution Account

Name on Account: __________________________________ Relationship to Recipient: ___________________________________

Bank Information: Name of Financial Institution (bank or credit union): _________________________________________________

Address ___________________________________________ City___________________________ State________ Zip__________

Account Number __________________________________ Routing Transit Number_______________________________________

As representative of the above-named Financial Institution, I certify this financial Institution is ACH capable and will receive and deposit the benefit payment to the account shown above in accordance with Part 102 of the Codes, Rules, and Regulations of the State of New York and to be bound by such rules. Payments credited to the account above will be available to the depositor immediately.

_______________________________________	________________________________________	_______________
Representative Signature	Representative Printed Name	Date