Section a *Required Fields Must Be Completed To Avoid Return of the Application and/or Delay in Processing the Application


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NameSection a *Required Fields Must Be Completed To Avoid Return of the Application and/or Delay in Processing the Application
A typeDocumentation




MISSOURI DEPARTMENT OF SOCIAL SERVICES

CHILDREN’S DIVISION

PO BOX 88, JEFFERSON CITY, MO 65103

APPLICATION FOR VENDOR DIRECT DEPOSIT

*Required Fields

SECTION A *Required Fields Must Be Completed To Avoid Return of the Application and/or Delay in Processing the Application

*1. TYPE OF ACTION (Check Only One)

 New Applicant or Re-Enrollment

 Change Direct Deposit Information

 Cancel Direct Deposit

*2. CONTRACT TYPE OR SERVICE PROVIDED (Check All That Apply)

Child Care  Foster Care/Adoption/Legal Guardianship

Children’s Treatment  Residential Treatment

 Other (Please Describe):

*3. INDIVIDUAL NAME(S) OR BUSINESS NAME

(All names on the contract must be listed here if contract is not under a business name.)      

*List Individual Name(s) of Business Owner(s)

A.      

B.      

C.      

*4. ADDRESS (number, street name, city, state, and zip code)

     

*5. VENDOR NUMBER OR DCN

     

*6. TAX ID/SSN

     /     

*7. TELEPHONE NUMBER (include area code)

   -   -    

SECTION B *Required Fields Must Be Completed To Avoid Return of the Application and/or Delay in Processing the Application

Note: A voided check or an official letter from your financial institution stating your name, the bank routing number and your account number must be attached to process the Direct Deposit Application. Starter checks and counter checks will not be accepted in place of a check or letter from your financial institution.

*1. NAME OF FINANCIAL INSTITUTION

     

*2. TYPE OF ACCOUNT (Check Only One)

 CHECKING ACCOUNT  SAVINGS ACCOUNT

*3. FINANCIAL INSTITUTION ADDRESS (number, street, city, state, and zip code)

     

*4. FINANCIAL INSTITUTION TELEPHONE NUMBER (include area code)

     

*5. 9 DIGIT ROUTING NUMBER

     

*6. ACCOUNT NUMBER

     

SECTION C *Required Fields Must Be Completed To Avoid Return of the Application and/or Delay in Processing the Application

I wish to participate in Direct Deposit and in doing so:


  • I (We) hereby authorize the State of Missouri to initiate credit entries (deposits) and to initiate, if necessary, debit entries (withdrawals), or adjustments for any credit entries made in error to my (our) account designated above.




  • I (We) understand that it is my (our) responsibility to notify the Children's Division when a change in banking information is made. This notification must be made at least two weeks prior to the scheduled direct deposit. Without this notification, I (we) understand that payments may be delayed.




  • I (We) understand that by endorsing or depositing checks that payment is made from Federal and State funds and any falsification, or concealment of material fact, may be prosecuted under Federal and State laws.




  • I (We) hereby authorize the State of Missouri to initiate payment adjustments made to this account that were intended for another vendor or another account.




  • I (We) understand the State of Missouri may terminate my (our) enrollment in the Direct Deposit program if the State is legally obligated to withhold part or all payments for any reason (for example, garnishment orders).




  • I (We) understand that the Children's Division may terminate my (our) enrollment if I (we) no longer meet eligibility requirements.




  • I (We) understand that this document shall not constitute an amendment or assignment of any nature whatsoever, or any contract, purchase order or obligation that I (we) may have with any agency of the State of Missouri.

All individuals listed on the contract and/or listed as business owners must sign and date the Application for Direct Deposit to authorize initiating, changing, or canceling this Direct Deposit Application.

*SIGNATURE INDIVIDUAL A

*DATE

     

*SIGNATURE INDIVIDUAL B

*DATE

     

*SIGNATURE INDIVIDUAL C

*DATE

     

ALL REQUIRED FIELDS MUST BE COMPLETED TO AVOID RETURN OF THE APPLICATION AND/OR DELAY IN PROCESSING THE APPLICATION

A VOIDED CHECK OR OFFICIAL LETTER FROM YOUR BANK MUST BE ATTACHED TO THIS FORM FOR PROCESSING
RETURN COMPLETED FORM AND ATTACHMENT TO:

CHILDREN'S DIVISION

PO BOX 88

JEFFERSON CITY, MO 65103




INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR DIRECT DEPOSIT

SECTION A - All fields in Section A are required fields.


1. Type of Action (Check Only One) – Check the box for the action you would like to accomplish by completing the Application for Direct Deposit.

  • New Applicant or Re-Enrollment – Check this box if this is a new request for direct deposit or if you previously had a direct deposit, but it has since closed and you would like to re-open the request.

  • Change Direct Deposit Information – Check this box to notify us of any change in the direct deposit request, including, but not limited to, change in routing number or account number, change in contract name, etc.

  • Cancel Direct Deposit – Check this box to notify us to cancel the direct deposit request. When the request to cancel the direct deposit is processed, you will no longer receive payments via electronic funds, but will begin to receive paper checks if you are entitled to payment.

2. Contract Type or Service Provided (Check All That Apply)

  • Child Care – Check this box if you or your business provides child care (license exempt/registered or licensed/contracted) and may receive payments from the State of Missouri.

  • Foster Care/Adoption/Legal Guardianship/Respite – Check this box if you hold a foster care, adoption, legal guardianship, or respite contract/agreement with the State of Missouri.

  • Children’s Treatment – Check this box if you or your business provide Children’s Treatment Services to clients of the State of Missouri.

  • Residential Treatment – Check this box if you or your business provide Residential Treatment Services to clients of the State of Missouri.

  • Other (Describe) – Check this box and describe what service you provide to clients of the State of Missouri, if none of the above applies to you or your business.

3. Individual Name(s) or Business Name – Write the names of each individual listed on the contract or the name of the business listed on the contract.

  • If the contract or agreement has more than one name listed, all names must be listed here.

  • If a business name is on the contract or is providing service, list each individual name of the business owner(s) in A, B, and/or C.

4. Address – Write the mailing address, including the number, street name, city, state, and zip code.

5. Vendor Number or DCN – Input your 9 digit Vendor Number (DVN) or 8 digit Departmental Client Number (DCN)

6. Tax ID/SSN – Input your FEIN or Social Security Number

7. Telephone Number – Input a telephone number (including the area code) where you can be reached, should there be any questions about the direct deposit application.

SECTION B - All fields in Section B are required fields.

NOTE: A VOIDED CHECK OR AN OFFICIAL LETTER FROM YOUR FINANCIAL INSTITUTION STATING YOUR NAME, THE BANK ROUTING NUMBER AND YOUR ACCOUNT NUMBER MUST BE ATTACHED TO PROCESS THE DIRECT DEPOSIT APPLICATION. STARTER CHECKS AND COUNTER CHECKS WILL NOT BE ACCEPTED IN PLACE OF A CHECK OR LETTER FROM YOUR FINANCIAL INSTITUTION.


1. Name – Input the name of your financial institution.

2. Type of Account (Check Only One)

  • Checking Account – Check this box if payment is to be direct deposited into a checking account.

  • Savings Account – Check this box if payment it to be direct deposited into a savings account.

3. Financial Institution Address – Input the address of your financial institution, including number, street name, city, state, and zip code.

4. Financial Institution Telephone Number – Input the telephone number (including the area code) of your financial institution.

5. 9 Digit Routing Number – Input the 9 digit routing number for your financial institution.

  • If you are submitting a voided check, the 9 digit routing number can be found at the bottom of your check. The 9 digit routing number is the first set of 9 numbers found at the bottom of the check, towards the left side.

6. Account Number – Input your account number.


  • If you are submitting a voided check, the account number can be found at the bottom of your check after the 9 digit routing number or after the check number.




SECTION C - All individuals listed on the contract and/or listed as business owners must sign and date the Application for Direct Deposit to authorize initiating, changing, or canceling this Direct Deposit Application.


Signature Individual A – Individual A must sign and date on this line.

Signature Individual B – Individual B must sign and date on this line.

Signature Individual C – Individual C must sign and date on this line.





In order to allow the Children’s Division and the State of Missouri, Division of Finance and Administrative Services to deposit payments into an account, you must complete all of the required fields on the Direct Deposit Application and attach a voided check or an official letter from your financial institution stating your name, the bank routing number and your account number. Starter checks and counter checks will not be accepted in place of a check or letter from your financial institution. With the exception of your signature(s), type or print the required information.

WHAT YOU CAN EXPECT




  • The Direct Deposit Application will be processed when a complete form is received, including all required fields and an attached voided check or letter from your financial institution.

  • Failure to complete all required fields on the form and attach a voided check or letter from your financial institution will cause the application to be returned to you for correction and will delay processing of the application.

  • You should begin receiving payments by direct deposit approximately 10-14 days after the Direct Deposit Application has been processed.

  • If you are entitled to any payments during the time it takes to process the Direct Deposit Application, the payments will be issued as paper checks.

CHANGING FINANCIAL INSTITUTIONS OR ACCOUNTS


Payments will continue to be deposited in the designated account at your financial institution until you notify the Children’s Division you wish to change the financial institution and/or account where the payments are deposited.

To make any changes to the financial institution and/or account where payments are deposited, you must complete a new Direct Deposit Application. All parties listed on the contract and/or listed as business owners, must review and sign, to authorize changes (including cancellations), to the Direct Deposit Application. Failure to notify the Children’s Division of a change in account information will result in a delay in receiving your payments.





ALL REQUIRED FIELDS MUST BE COMPLETED TO AVOID RETURN OF THE APPLICATION AND/OR DELAY IN PROCESSING THE APPLICATION

A VOIDED CHECK OR OFFICIAL LETTER FROM YOUR BANK MUST BE ATTACHED TO THIS FORM FOR PROCESSING
RETURN COMPLETED FORM AND ATTACHMENT TO:

CHILDREN'S DIVISION

PO BOX 88

JEFFERSON CITY, MO 65103






CD-122 (04/12)


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