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





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



____________________________________________   __________________________

                              Signature (required)                                                                  Date



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


If you would like to receive notifications from the State Disbursement Unit that there has been a disbursement on your child support case listed above, please complete the requested information below.

Mobile phone number: __________________              Email: ________________________________

    (Standard Text Messaging rates may apply)                                                        (Please print and write clearly)

Preference (Circle One): Text Message     Email Message

If both mobile phone number and email address are provided but no preference is indicated the notification method will default to email.