Louisiana Direct Deposit Form 2Louisiana Direct Deposit Form 2
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OFS DD 2
Rev. 12/10
06/10 Issue Obsolete

Louisiana Department of Children and Family Services
Child Care Assistance Program
DIRECT DEPOSIT AUTHORIZATION FORM

Return to:
Provider Directory
P.O. Box 94065
Baton Rouge, LA 70804
Please TYPE or Legibly PRINT all information in INK.
Section 1:

PARTICIPANT CASE INFORMATION

Name:

Date of Birth:

Mailing Address:
City/State/ZIP:
Daytime Telephone #: (

)

Home Telephone #: (

Social Security Number:

)

Provider Number:

Section 2:

FINANCIAL INSTITUTION INFORMATION

Name of Financial Institution:
Mailing Address:
City/State/ZIP:
Telephone #:

(

)

Routing Number:
Account Type (Check One):
Check One:

New Request

Account Number:
Checking*

Savings*
Change Account

Cancel Direct Deposit

*Note: Be sure to include a voided check for checking accounts. For savings accounts, submit a statement from your financial
institution showing the account number and routing number.

Section 3:

AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT OF PAYMENTS

I