AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT



Children, Youth and Families Department

AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT/PAYMENT METHOD

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|PROVIDER NAME: |

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|FACTS PROVIDER NUMBER: |

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|SOCIAL SECURITY NUMBER: OR FEDERAL TAX ID NUMBER: |

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|DISBURSEMENT TYPE: Check/Warrant |ACCOUNT TYPE: Savings Account |

|Direct Deposit |Checking Account |

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|DIRECT DEPOSIT INFORMATION |

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|This section to be completed only if you want your child care reimbursement payment automatically direct-deposited into a financial institution/credit union. Please allow 30 days from the completion of this form for |

|direct deposit to take effect. |

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|Enter your financial institution/credit union, bank routing number and account number. |

|(Note: It is your responsibility to verify these numbers with your financial institution/credit union) |

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|Name of financial institution/credit union: |

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|Routing Number: Account Number: |

|Certification: |

|I authorize New Mexico Children, Youth and Families Department to make payment as indicated in disbursement type above. I certify that these accounts shown are correct. I authorize the State of New Mexico to make |

|payroll adjustments to these accounts. |

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|NOTE: If direct deposit is with checking account please include a voided check from the account above. |

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|Provider Signature: Date: |

Please return to: Children, Youth and Families Department, Early Childhood Services, P.O. Drawer 5160, Santa Fe, NM 87504-5160

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