MDHS-CSE-687
Revised 11-21-19
AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT
Agency: Mississippi Department of Human Services (MDHS)
Division of Child Support Enforcement (DCSE)
Direct Deposit Unit
P.O. Box 352 Jackson, MS 39205-0352
Please check one: START DIRECT DEPOSIT ( ) CHANGE DIRECT DEPOSIT ACCOUNT ( )
STOP/TERMINATE DIRECT DEPOSIT AGREEMENT ( )
I hereby authorize the agency named above to deposit my child support payments directly to my
( ) CHECKING account. YOU MUST submit a copy of a government-issued photo
identification, preprinted voided blank check, deposit slip, or a current date letter (bank’s
letterhead) from your bank that includes your account and routing bank numbers with this
agreement to Mississippi Department of Human Services, Division of Child Support
Enforcement, Direct Deposit Unit, P.O. Box 352, Jackson, MS 39205-0352. Handwritten
checks/deposit slips or bank statements are not acceptable. Write “void” across your blank
check or deposit slip before submitting with this agreement. The account must be in the name of
the custodial parent as the primary or joint account holder with the social security number verified
in our case record.
I hereby authorize the agency named above to deposit my child support payments directly to my
( ) SAVINGS account. YOU MUST submit a copy of a government-issued
identification, current date letter (bank’s letterhead) from your bank, savings and loan, or credit
union which includes the name of the account holder (s) and account and routing bank numbers
with this agreement to Mississippi Department of Human Services, Division of Child Support
Enforcement, Direct Deposit Unit, P.O. Box 352, Jackson, MS 39205-0352. The account must
be in the name of the custodial parent as the primary or joint account holder with the social security
number verified in our case record.
Account and routing numbers are generally found on the bottom of your checks or at the bottom
of preprinted deposit slips, and these numbers must be clearly visible and identifiable on the
instrument provided to prevent processing delays. This authorization agreement will not be
processed if the information is not identifiable. MDHS will contact you if we cannot process your
request.
If I receive any money that was sent to me in error, I give permission for MDHS to recover the
money from future child support payments. I also authorize my current/existing bank, savings and
loan or credit union to credit/debit my account accordingly.
Financial Institution Name: ______________________________ Branch: __________________
City: ____________________________ State: ________________ Zip: ___________________
MDHS-CSE-687
Revised 11-21-19
Page 2
MDHS reserves the right to cancel the direct deposit agreement if three (3) or more requests
to change financial institutions are received during a 12-month period.
Payments not provided through direct deposit, will be provided through a MDHS-issued
debit card. While the debit card is issued free of charge, there may be fees depending on how the
card is used. Information about debit card fees can be found at https://www.mdhs.ms.gov/wp-
content/uploads/2019/08/MS-EPC_All-Forms.pdf.
A parent who receives child support can only make one (1) stop/terminate request from direct
deposit method back to the debit card.
By checking the “Stop/Terminate” option above, I hereby authorize the agency named above to
terminate my pre-existing direct deposit agreement.
Once MDHS receives a correctly completed authorization agreement form or termination
request, it takes approximately two weeks for processing to be completed. A copy of
government-issued photo identification must be included with all requests to start direct
deposit, change accounts, or terminate direct deposit.
By signing this agreement, I acknowledge that the agreement shall remain in effect until
MDHS receives a signed form requesting to change this agreement to a different account, or
MDHS receives a written notice from me to terminate this authority, and MDHS has a
reasonable time to act on the request. I acknowledge that MDHS may cancel this authority
in accordance with this agreement. I acknowledge that if I terminate this agreement, MDHS
will issue a debit card for future child support payments and that fees may be assessed
depending on how I use the card. I also acknowledge that I have read the debit card fee
disclosure statements available on the MDHS website.
____________________________ ____________________________
Custodial Parent Name (please print) Social Security Number
____________________________ ____________________________
Custodial Parent Signature Date
____________________________ ____________________________
Current Mailing Address Phone Number
______________________________________________________________________________
STATE OFFICE USE ONLY
Received Date: ___/___/_____ System Entry Date: ___/___/_____ MDHS Staff: ____________
