DIRECT DEPOSIT AUTHORIZATION
Michigan Department of Health and Human Services
Michigan State Disbursement Unit
Check one box and complete the entire form.
New	Change	Cancel
Name (Last, First, Middle) (Print)
Home Telephone Number	Work Telephone Number	Date of Birth (MMDDYYYY)
Current/New Address (Number, Street, Apt. Number, City, State, Zip Code, Country (if not US))
Social Security Number	Case ID or Court Case (Docket) Number
(Identify one case number, but multiple cases may be paid in a single deposit.)
Number	County
Bank Name
Bank Routing Number	Bank Account Number
Checking Savings
For a CHECKING account: Write VOID on an unused check and attach here. For a SAVINGS account: Contact your bank and obtain written verification of your account and routing numbers. Attach that verification to this form.	John and Mary Jones 1234 123 Main Street Anytown, MI 48888 Pay to: $________ VOID DOLLARS Anytown Bank Anytown, MI 48888 For: SAMPLE: Do not complete |:072412345 | 0012300456 1234
Routing Number (9 digits)	Account Number (up to 17 digits)
I authorize the State of Michigan to deposit all support payments into the designated financial institution and account, and to initiate correcting entries, if necessary. I understand that the deposits will be made electronically, under the rules of the National Automated Clearing House Association (NACHA), and the State of Michigan. This authorization will remain in effect until cancelled by me with written notification to the state, or cancelled by the financial institution or the State of Michigan, at which time they will notify me by mail at the most current address they have on file for me.
Sign Here	Date
Mail or fax this form to: MiSDU Attn: Direct Deposit PO Box 30354 Lansing, MI 48909-7854 FAX: 517-318-4697
The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, gender identification or expression, sexual orientation, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.