Program(s): Branch: Worker ID:
Case name: Case number(s):
Seniors and People with Disabilities
In Home Services, Independent Choices Program
Request for Direct Deposit A Safer, Easier Way to Put Your Benefits in Your
Independent Choices Bank Account
The Department of Human Services (DHS) offers direct deposit. That means DHS can deposit your
benefit right into your bank or credit union account.
Direct deposit is free. Once it is set up, there is nothing else you need to do.
Signing up for direct deposit is mandatory.
Direct deposit can:
Save you time and money by ending the need for special trips to make deposits. You can avoid
traffic, waiting in line or going out in bad weather.
Save you the worry of losing money. You will always know that your benefits will go directly
into your account.
To sign up for this service: Complete the non-shaded part. Be sure to sign your name on the
By signing this form, I authorize the Department of Human Services to make provider payment
deposits into my account at the bank or credit union listed above. I understand that direct deposit
transactions made to my account must comply with U.S. and Oregon laws.
International Transaction Certification
I certify that the entire amount of my direct deposit payment is NOT deposited to a financial
institution outside the U.S. Seniors and People with Disabilities (SPD) will not process direct
deposits into accounts outside the U.S.
Please print your name: Social Security number:
Have your bank or credit union complete the shaded portion.
Account name: Routing number: Account number:
Financial institution: Type of account: Bank employee initial:
Original signature required – No faxes or copies.
Attach a check with VOID written on it.
When completed, return the form with your voided check attached to your case worker at
the local SPD/AAA office. Then the local office needs to send these to central office.
It takes about 30 days for processing before DHS makes a deposit.
This document can be provided upon request in alternative formats for individuals with disabilities. Other
formats may include (but are not limited to) large print, Braille, audio recordings, Web-based communications
and other electronic formats. E-mail firstname.lastname@example.org , call 1-866-294-0153 (voice) or call 1-800-282-8096
(TTY) to arrange for the alternative format that will work best for you.
DHS 7262i (04/10), recycle prior versions