CSSD Check Reissue Request {04-1013}

Alaska Department of Revenue Please Reply To: Child Support Services Division CSSD, MS 12 550 W. 7th Ave., Suite 310 Anchorage, AK 99501-6699 www.childsupport.alaska.gov CSSD Check Reissue Request Date of Request: Case Number: Name: Address: If New Address: Check number: Check number: Amount of Check: Amount of Check: Date Issued: Date Issued: Please issue a Stop Pay on the above noted check(s) for the following reason: Never Received Lost Stolen Other I agree not to cash this/these check(s) if received and will return it/them to the Child Support Services Division. If I cash this/these checks I am giving CSSD permission to automatically recover these amounts from Future Monthly Support Obligations. Signature Printed Name Date received in SDU Date request completed CSSD 04-1013 (Rev: 2//1) TOLL FREE (In-state, outside Anchorage): (800) 478-3300 ANCHORAGE: (907) 269-6900 FAX: (907) 787-3322 FAIRBANKS: (907) 451-2830 TDD machine only: (907) 269-6894 / TDD machine only, toll free (In-state, outside Anchorage): (800) 370-6894 American LegalNet, Inc. www.FormsWorkFlow.com 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: On time, every timeSaves you trips to the bankWorks, even when you are awayfrom home Sign up for Direct Deposit today! Getting started is easy 205 Simply fill out the Authorization Form below. Just be sure to sign and form and mailto 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: a check or depsit 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) 269-6. Only one form is required even if you have multiple cases. Gives you quick access to your money Eliminates the risk of lost or stolen checksEnables you to avoid other feesHelps protect the environment American LegalNet, Inc. www.FormsWorkFlow.com