Authorization Agreement for Direct Deposit s2

Children, Youth and Families Department

AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT/PAYMENT METHOD

PROVIDER NAME:
FACTS PROVIDER NUMBER:
SOCIAL SECURITY NUMBER: OR FEDERAL TAX ID NUMBER:
DISBURSEMENT TYPE: Check/Warrant
Direct Deposit / ACCOUNT TYPE: Savings Account
Checking Account

DIRECT DEPOSIT INFORMATION

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.
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)
Name of financial institution/credit union:
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.
NOTE: If direct deposit is with checking account please include a voided check from the account above.
Provider Signature: Date:

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