Form Ocs Dd 1 – Fill Out and Use This PDF

AUTHORIZATION FORM: DIRECT DEPOSIT

Please type or legibly PRINT all information below in ink.

SECTION 1

TIPS Provider #:

First Name:

M.I.

Last Name:

Date Of Birth:

E-MAIL Address:

Mailing Address1:

Mailing Address 2

City:

State:

Zip:

Parish:

Daytime Telephone:

Home Telephone:

Social Security Number:

Tax ID Number:

SECTION 2 FINANCIAL INSTITUTION INFORMATION

Name of Financial Institution:

City:

State:

Zip:

Parish:

Telephone:

Check one:

Corporate Account

Personal Account

Routing Number:

Account Number:

Account Type

(Check one):

Checking Account

Savings Account

Check one:

New Request

Change Account

Cancel Direct Deposit

*Note: Be sure to include a pre-printed deposit slip or voided check. If the account is a savings account at a credit union or savings and loan, a financial institution printout showing the account number and routing number is required.

Section 3: Authorization Agreement for the Direct Deposit of Provider Payments

I authorize Office of Community Services (OCS) to deposit my Provider payments directly into my checking account or savings account as specified above. I understand the deposits/adjustments will be made electronically by Automated Clearing House Network (ACH) transactions and I must allow the Federal Reserve two working days from the disbursement date to have the transactions funds available to my financial institution. I also understand the following: It is my responsibility to provide correct routing and account information for ACH transmissions by attaching a voided check or pre-printed deposit slip from my financial institution. I will immediately notify OCS if my banking information changes. I must submit a new authorization form to change my direct deposit. I can stop my direct deposit by notifying OCS. I must notify OCS of any changes to my address. I must include my name and TIPS provider number on all correspondence regarding direct deposit. OCS will notify me of deposits to my account with a Remittance Advice. To verify when a payment is posted to my account and funds are available, I will have to contact my financial institution.

By signing below I signify that I have read and agree to all of the conditions listed above.

Signature:

Date Signed:

Office Use Only

Sent by:

Date Received:

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Entered By:

Form OCS DD-1

Issued: 4/06