CCA-1140A DIRECT DEPOSTI ENROLLMENT.PDF
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CCA-1140A FORFF (9-22) ARIZONA DEPARTMENT OF ECONOMIC SECURITY Division of Child Care DIRECT DEPOSIT ENROLLMENT CENTERS AND GROUP HOMES Initial Request Change Request Name Title Provider ID Number Name of Facility Provider ID Number Name of Facility Provider ID Number Name of Facility Provider ID Number Name of Facility Provider ID Number Name of Facility Provider ID Number Name of Facility Name of Corporation Mailing Address (No., Street) City State ZIP Code Daytime Phone NO. Name of Financial Institution Routing NO. Account NO. I authorize the State of Arizona and the financial institution to process credit entries to the bank account number stated on this form. I will notify the State of Arizona of any known changes or closure of my bank account. When the State of Arizona is notified by my financial institution of changes affecting this direct deposit, the State of Arizona is authorized to make the applicable changes. This authorization is to remain in effect until a new authorization is received. Signature Please submit this form with a copy of a voided check to: Department of Economic Security Division of Child Care Payment Processing Unit P.O. Box 6123, MD 85J1 Phoenix, AZ 85005 NOTE: Your enrollment cannot be processed without a copy of a voided check attached. Please allow 60 days for Direct Deposit to start. Thank you. Equal Opportunity Employer / Program • Auxiliary aids and services are available upon request to individuals with disabilities • To request this document in alternative format or for further information about this policy, contact 602-542-4248; TTY/TDD Services: 7-1-1• Disponible en español en línea o en la oficina local