Child Care Provider Direct Deposit Enrollment Form

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Child Care Provider Direct Deposit Enrollment Form Powered By Docstoc
					SD EForm - 1055     V1           Complete and use the button at the end to print for mailing.          HELP

                             SOUTH DAKOTA DEPARTMENT OF
                                   SOCIAL SERVICES

                          DIRECT DEPOSIT ENROLLMENT FORM
                           OFFICE OF CHILD CARE SERVICES


  Initial Request                                Change Request


I authorize the Department of Social Services to deposit my provider payments directly into the
bank account listed below, and if necessary, reverse any incorrect credit entries made in error. I
acknowledge that a new enrollment form must be completed if I choose to change banks
or accounts.

Name                                                              Provider Number
Business Name
Mailing Address
City                                         State                                      Zip
Daytime Telephone Number
Your Tax ID or Social Security Number
Name of Your Bank
Your Bank’s Address
City                                          State                                     Zip
Bank Telephone Number (if known)
Account Information (Check one)                                   Checking                      Savings
Your Signature                                                                                  Date


Your enrollment cannot be processed without a voided check or a voided
savings account deposit slip attached.
Mail this completed form and a voided check or savings account deposit slip to:
                                         Child Care Services
                                   Department of Social Services
                                        700 Governor’s Drive
                                          Pierre SD 57501
Before Mailing this document, did you?       Fill in each blank? Attach a VOIDED CHECK?



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