ILLINOIS

STATE DISBURSEMENT UNIT

P.O. Box 5921

Carol Stream, IL 60197-5921

Customer Service: (877) 225-7077

 

DIRECT DEPOSIT AUTHORIZATION AGREEMENT

 

I, hereby authorize the State Disbursement Unit, (SDU) to initiate credit entries for deposit of child support payments and if necessary, to initiate debit entries and adjustments for any credit entries made in error to my account at the Depository Institution named below.

Account Type (check one)

                Checking Account (attach a Voided Check)

Savings Account (Contact your bank to obtain the bank routing number and savings account number)

 

Name of Bank

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

City

 

State

 

Zip

 

Phone

 

 

 

 

 

Bank Routing Number

 

 

9-digit number on the bottom left of the check

Account Number

 

 

Numbers following Routing Number

 

This authorization is to remain in full force and effect until the SDU has received written notification from me of its termination in such time and in such manner as to afford the SDU and the Bank a reasonable opportunity to act on it.

 

First Name:

 

Last Name:

 

Social Security Number:

 

Daytime Phone Number:

 

 

List all the docket numbers to which direct deposit authorization agreement will apply:

Docket Number

 

Issuing County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_____________________________________________  __________________________

            Signature (required to validate this request)                                              Date

 

Please fax the completed form with the above referenced information to (630) 221-2312 or mail to the Illinois State Disbursement Unit at the above address.  The process to establish this service requires approximately 2-4 weeks.  In the interim, checks will continue to be mailed to your address.