Direct Deposit  
                                      Stop going to the bank to cash your checks and start receiving your 
                                      payments in your bank account.   Here are just a few reasons why 
                                      you should sign up for Direct Deposit today: 
                                      •     It’s easy and secure                     • Gives you quick access to your money
                                      •     On time, every time                      • Eliminates the risk of lost or stolen checks
                                      •     Saves you trips to the bank              • Enables you to avoid other fees
                                      •     Works, even when you are away            • Helps protect the environment
                                            from home

                               Sign up for Direct Deposit today!  Getting started is easy… 

                               Simply fill out the Authorization Form below. Just be sure to sign and date the
                               form and fax it to 907-787-3220 or mail it to the following address: 
                                                                            Child Support Services Division 
                                                                            550 W 7th Ave, Suite 310 
                                                                            Anchorage, AK 99501-6699 
                               Direct Deposit Authorization Form 

 Custodial Parent's Name (please print) 
                                                  First              Middle Initial         Last 

Mailing Address 
                  Street Address or PO Box                                  City            State            Zip 

Daytime Phone (____ ) __________    Social Security Number_______________________________ 
                                                                        SSN is not required for direct deposit.  It is used to assist 
                                                                       In the identification of your bank and financial account. 
Date of Birth ____/____ /_____           CSSD Member ID#   _________________________________ 
                                                                    This is the 8-digit Member Number assigned by CSSD, not your  
                                                                    case number. 

Account Type  Checking      Savings        Name of bank or financial institution: ______________________________ 
                  Attach a check or deposit slip, locate your banks routing number and your account number. 

Routing Number _________________________                  Account Number ___________________________________ 

I authorize the State of Alaska CSSD to make necessary adjustments to the above account to correct any credit 
entries made in error. I understand that the CSSD will make a reasonable effort to notify me within 24 hours when 
an adjustment is made. This authority remains in effect as long as I have an open child support case with the State 
of Alaska CSSD. I understand that 30 days written notice is required to change financial institutions, account 
numbers, or account type and that I must notify CSSD if I close my account or change my mailing address. 

Signature (required) _________________________________  Date (required)___/_____/____ 
For more information, call the Alaska Child Support Services Division at (907) 269-6900. 
                  Only one form is required even if you have multiple cases. 

04-0008 (07/09/15)