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: |
| | |
|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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