MISSOURI DEPARTMENT OF SOCIAL SERVICES

AGREEMENT FOR DIRECT DEPOSIT

PART I Completed by county FSD office
START I want the Missouri Department of Social Services to deposit my assistance payments in my bank account. I authorize my financial institution to credit the deposits to the account named below. (GO TO PART II)
CHANGE I want the Missouri Department of Social Services to change my direct deposit to the bank account named below. I authorize my financial institution to credit the deposits to this account. (GO TO PART II)
HOLD I do not have a bank account yet but I will open an account. I want the Missouri Department of Social Services to deposit my assistance payments to my account as soon as the bank notifies them the account is open. (GO TO PART III)

PART II Completed by county FSD office
NAME OF FINANCIAL INSTITUTION
ADDRESS (CITY, STATE, ZIP CODE)
BANK NUMBER	ACCOUNT NUMBER
ACCOUNT TYPE CHECKING SAVINGS (Attach a blank check with VOID written across it.) (Attach a savings deposit slip showing your account number with VOID written across it.)
NAME (PRINT)	DCN	COUNTY
SIGNATURE	DATE
PART III FSD complete NAME, DCN, SSN. Bank complete banking information.
CUSTOMER NAME	CUSTOMER DCN
CUSTOMER SOCIAL SECURITY NUMBER - -	BANKING ROUTING NUMBER	ACCOUNT NUMBER
IS THIS ACCOUNT A SAVINGS ACCOUNT? YES, ENTER 1; NO, ENTER 0	BANKER’S TELEPHONE NUMBER	TELEPHONE EXTENSION
CUSTOMER: I wish to receive my cash benefit by direct deposit. I do not have a bank account now but intend to open one immediately. I understand direct deposit of my cash benefit will start once my account is open.
CUSTOMER SIGNATURE	DATE
MO 886-2841 (10-05)E/10-2005	DISTRIBUTION: WHITE - CLIENT; CANARY - CASE RECORD	IM-20

INFORMATION ABOUT DIRECT DEPOSIT OF CASH ASSISTANCE Once you have signed up for direct deposit, it will take at least ten days to verify your bank account. Any payment made before the bank verifies your account will be by check mailed to you or by electronic benefit transfer. Your monthly assistance payment will be transferred to your bank on the date that checks for your type of assistance are mailed. Due to differences in local banks’ procedures, your assistance payment may be credited to your account on that day or not until a later date. If you have a question about whether a payment has been credited to your account, you can get this information from your bank. If you want to change your direct deposit to a different bank account, you must notify your caseworker immediately and request that direct deposit to that account be stopped. If you do not do this, your payment will be delayed. Any payment made after your direct deposit account is closed will be in the form of a check mailed to you at your mailing address.
MO 886-2841 (10-05)/E 10-2005	IM-20