New York State Child Support
Direct Deposit Enrollment Form
For Direct Deposit ONLY. Do not use this form if you wish to receive a debit card. (Please type or print clearly using black ink.)
Directions:
1. Complete BOTH sections below and return this form, ONLY if you wish to enroll in Direct Deposit.
2. Your name must appear on your bank or credit union account.
3. Your enrollment cannot be processed without your New York Case Identier.
4. If you are receiving payments on more than one child support account in New York State, you will need to complete and submit a
separate form for each child support account. Be sure to include the New York Case Identier.
5. Return the completed form to: NYS Child Support Processing Center, PO Box 15367, Albany, NY 12212-5367.
6. For any questions on how to complete this form, or to request a debit card, contact the Child Support Helpline at 888-208-4485,
TTY 866-875-9975, Relay Service (fcc.gov/encyclopedia/trs-providers).
A. Required Information for Enrolling in Direct Deposit to be Completed by the Enrollee
You must provide the following information about yourself and your child support account.
If ANY information is missing, the form will be returned for completion.
First Name MI Last Name
Mailing Address City State ZIP
Date of Birth (MM/DD/YYYY) Social Security Number
New York Case Identier (e.g., AB12345C1) County Name
Phone Number Email Address (Optional)
I certify that I am entitled to child support, or combined child and spousal support, payments for the above New York Case Identier. I
authorize that all my child support and/or spousal support payments to the nancial institution named below be deposited in the account
indicated by the nancial institution. This authorization will remain in force until I provide written notice of cancellation. I understand and
agree to a reasonable time to process the cancellation notice.
Signature Date (MM/DD/YYYY)
B. Required Information to be Completed by the Financial Institution
Please take this form to your bank or credit union for the following information and their signature:
Bank Information:
Name of Financial Institution (bank or credit union):
Mailing Address City State ZIP
Account Information:
Checking Savings (This CANNOT be a Trust Account to benet another or a Foreign Financial Institution Account)
Account Number Routing Transit Number
As representative of the above-named Financial Institution, I certify this nancial Institution is ACH capable and will receive and deposit
the support payments to the bank account number shown above.
Representative Signature Representative Printed Name Date (MM/DD/YYYY)
Direct Deposit Enrollment Form (Rev. 11/21)
