Indiana Direct Deposit Form 1
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DIRECT DEPOSIT AUTHORIZATION
P.O. Box 6098
Indianapolis, IN 46206-6098
Phone: 317-233-5437 or 1-800-840-8757
Fax: 317-241-9635

New Request

Change Request

Please complete this form and mail it to the address above if you wish to have your support payments deposited automatically
into your checking or savings account. You may choose only one account to which these funds will be deposited, regardless of
the number of child support cases that you have open in the State of Indiana. No separate notice of deposit will be sent to you
when funds are disbursed. Please keep a copy of this form in your records. If you change accounts, you must complete a new
authorization form.
Name of custodial party

Social Security number of custodial party *

Home address (number and street)

Daytime telephone number

City

State

ZIP code

City

State

ZIP code

Name of your financial institution (bank, credit union, etc.)

Address of your financial institution (number and street)

Telephone number of your