Depository Direct Deposit Authorization Form {769}

CLERK OF COURTS AND COUNTY COMMISSION Eleventh Judicial Circuit Dade County, Florida HARVEY RUVIN CENTRAL DEPOSITORY Clerk 370 S.E. First Street, Room 200 Miami, Florida 33131-2002 Telephone (305) 275-1122 Dear Central Depository Clients: I am most pleased to inform you that recent technological advancements within the Clerks Office have allowed the Central Depository to now offer Direct Deposit of your child support payments to your checking or savings account. This new service will allow you to receive your funds quickly and accurately. You will no longer need to make extra trips to the bank and wait in line to cash your check. Rather, Central Depository will deposit your child support payment directly into your bank account. To take advantage of this option, please take the enclosed application form to your financial institution for completion. Return the form along with a copy of your deposit slip or a voided check to: CENTRAL DEPOSITORY 370 SE First Street, Room 200 Miami, Florida 33131-2002 Once your financial institution has completed and returned the required form, please allow approximately two weeks after receipt for information verification and processing requirements. We hope you are pleased with this new service. My staff and I are committed to providing the best possible service to you, utilizing meaningful technological advances as they occur. With best wishes to you and your family; I am, sincerely, Harvey Ruvin, Clerk Administrative Services Division
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Traffic Division <<<<<<<<<********>>>>>>>>>>>>> 2 CENTRAL DEPOSITORY DIRECT DEPOSIT AUTHORIZATION FORM SECTION 1 NAME: ____________________________________________________ LAST FIRST M.I. CENTRAL DEPOSITORY ACCOUNT #: _________________________ SOCIAL SECURITY #: ________________________________________ ADDRESS: _______________________________________________ _______________________________________________ CITY: _______________________________________________ STATE: _____________________ ZIP: ___________________ HOME PHONE: _________________________WORK PHONE: _________________________ I authorize the Clerk of Circuit Court, Central Depository to make deposits to the account listed below. Central Depositor may makedeposits to this account until I cancel the authorization and Central Depository has time to act on it. This request cancels any other directdeposits I have in place with Central Depository. If funds are mistakenly deposited into my account, I authorize Central depository todeduct the amount of the error from my account, or from my future payments. SIGNATURE: ________________________________________DATE: ______________________ Please attach a voided check and have your financial institution complete 2. SECTION 2 Name and Address of Financial Institution: ___________________________________________________ ___________________________________________________ ___________________________________________________ Type of Depositor Account:_____ Checking _____ Savings Depositor Account Number: Routing Number: Check Digit Depositor Account Title: __________________________________ FINANCIAL INSTITUTION CERTIFICATION I confirm the identity of the above named payee and the account number and title. As representative of the above named financial institution,I certify that the financial institution agrees to receive and deposit the payment identified above in accordance with NACHA operating rulesand regulations. Representatives Name: _______________________________Signature of Representative: ________________________________Telephone Number: __________________________________Date: __________________________________________________ CLK/CT 769 9/95