Get Otda Sm Ssp Otda Ny Gov

LDSS-5025 Rev. 7/15 NYS OTDA State Supplement Program SSP Direct Deposit Enrollment Form Directions To be completed by individuals who receive only SSP benefits. BOTH sections must be completed. Return the completed form to NYS OTDA State Supplement Program PO Box 1740 Albany NY 12201 or by FAX to 518-486-3459 or Email the hand signed form to otda.sm.ssp otda.ny. Individuals receiving federal SSI benefits need to contact SSA. Complete this form ONLY if you wish to enroll in Direct Deposit. gov Please contact the SSP Customer Support Center at 1-855-488-0541 with any questions. The following information must be provided* If ANY information is missing the form will be returned for completion* Recipient Name Last First Daytime Phone Number - MI Recipient Mailing Address City Date of Birth MM/DD/YYYY / / State Zip Code Last Four Numbers of SSN XXX -XX- I certify that I am entitled to the benefits associated with the NY State Supplement Program SSP. In signing this form I authorize the SSP to send my benefits to the financial institution named below to be deposited into the account indicated by the financial institution* This authorization will remain in force until I provide written notice of termination* Print Name Signature Date ACCOUNT INFORMATION Please take this form to your bank or credit union for the completion of the information below. You may also choose to attach a voided preprinted not starter check containing your name and address or an account deposit form containing your name and address. This CANNOT be a Trust Account to benefit another OR a Foreign Financial Institution Account Account Information Checking Savings Name on Account Relationship to Recipient Bank Information Name of Financial Institution bank or credit union Address City State Zip Account Number Routing Transit Number As representative of the above-named Financial Institution I certify this financial Institution is ACH capable and will receive and deposit the benefit payment to the account shown above in accordance with Part 102 of the Codes Rules and Regulations of the State of New York and to be bound by such rules. Payments credited to the account above will be available to the depositor immediately. Representative Signature Date. gov Please contact the SSP Customer Support Center at 1-855-488-0541 with any questions. The following information must be provided* If ANY information is missing the form will be returned for completion* Recipient Name Last First Daytime Phone Number - MI Recipient Mailing Address City Date of Birth MM/DD/YYYY / / State Zip Code Last Four Numbers of SSN XXX -XX- I certify that I am entitled to the benefits associated with the NY State Supplement Program SSP. In signing this form I authorize the SSP to send my benefits to the financial institution named below to be deposited into the account indicated by the financial institution* This authorization will remain in force until I provide written notice of termination* Print Name Signature Date ACCOUNT INFORMATION Please take this form to your bank or credit union for the completion of the information below.