ILLINOIS

STATE DISBURSEMENT UNIT

P.O. Box 5921

Carol Stream, IL 60197-5921

Customer Service: (877) 225-7077

 

DIRECT DEPOSIT CANCELLATION FORM

 

 

First Name:

 

 

 

 

 

Last Name:

 

 

 

 

 

Social Security Number:

 

 

 

 

 

Street Address:

 

 

 

 

 

 

 

 

 

 

 

City:

 

State

 

Zip

 

 

 

 

 

 

 

Bank Name:

 

 

 

 

 

Bank Account Number:

 

 

 

 

 

Bank Routing Number:

 

 

 

 

 

 

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

 

Docket Number

 

Issuing County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I, _____________________________, do not want my child support payments to be paid via direct deposit anymore.

 

 

____________________________________________   __________________________

            Signature (required to validate this request)                                            Date

 

 

 

 

Please fax the complete form to (630) 221-2312 or mail to the Illinois State Disbursement unit at the above address.