Free CCSD0002 - Illinois

Authorization to Cancel Electronic and Bank-By-Mail Direct Deposit

(12/19/03) CCSD 0002

OFFICE OF THE CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Child Support 28 North Clark Street Room 200 Chicago, Illinois 60602 Phone: (312) 603-2000 Fax: (312) 345-4146

AUTHORIZATION TO CANCEL ELECTRONIC AND BANK-BY-MAIL DIRECT DEPOSIT
PLEASE WRITE THE ACCOUNT NUMBER YOU WANT US TO CANCEL ON THIS FORM! I am currently a participant in the Clerk's and/or SDU's direct deposit program, but hereby request to be cancelled from this program. I understand that my child support payments will be mailed to the address on our system until further instructions are received. NAME: ______________________________________________________ COURT DOCKET NUMBER: ___________________________________ DAY TIME PHONE NUMBER: (________) _________________________ BANK NAME: _________________________________________________ BANK CITY: __________________________________________________ BANK ROUTING NUMBER: _____________________________________ ACCOUNT NUMBER:___________________________________________ TYPE OF ACCOUNT (CIRCLE ONE)
CHECKING SAVINGS

________________________________________ ______/______/______
SIGNATURE DATE SIGNED NOTARY: Please put your seal in this space

Subscribed and sworn to before me this:

_______ day of ___________________, ________
My commission expires ______/______/______ Check if seal is embossed !

______________________________________
Notary Public Signature

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FOR COMPANY USE ONLY Old & New Att'd: __________________________ Terminated from SDU on: ______/______/______ Deleted from PNDD on: ______/______/______ Deleted from T-KIDS on: ______/______/______

DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS