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Get Oregonchildsupport Gov My Account

To change financial institutions or accounts I will complete and submit a new Authorization form. By signing this form I authorize the named financial institution to assist the CSP in validating the account information provided by me as related to the requirements of this application. INTERNATIONAL TRANSACTION CERTIFICATION I certify that the entire amount of my direct deposit payment IS NOT deposited to a financial institution outside the U.S. NOTE If your entire net payment IS directed outside the U.S. contact the Oregon Child Support Program. Print Reset ReliaCard OREGON ELECTRONIC DISTRIBUTION ENROLLMENT/AUTHORIZATION FORM Send completed authorization to DOJ / DCS P. O. Box 14320 Salem OR 97309 OR Fax to 503 986-2416 Required Fields. Incomplete Authorizations may be returned to you causing a delay in your request. PLEASE PRINT CLEARLY IN BLACK OR BLUE INK Applications completed with red ink or pencil will be returned* PERSONAL INFORMATION CSP Case Number s Include all Oregon CSP case numbers you want deposited into this ReliaCard account. Please deposit payments for ALL of my active cases into a single ReliaCard account 0 41 YES NO If you would like to include additional cases please write them on a separate piece of paper or check the box above if appropriate. Name The name that s currently on your child support checks LAST Date of Birth mm/dd/yyyy / FIRST MI - Social Security Number Current Address Street Address P. O. Box / Apt City State Zip Code Country Contact Phone area code Alternate Phone area code Please check this box to give the Child Support Program permission to leave a detailed message about this application if needed AUTHORIZATION I certify I am entitled to the payments for the cases listed above. I authorize the Oregon Child Support Program CSP to initiate credit entries of my child support payments and if necessary debit entries for transactions made in error into the account above. I understand my payments will continue to be deposited in this account and this authorization will remain in full force and effect until the CSP receives written notification from me of termination or change of account or financial institution at such time and in a manner to provide a reasonable opportunity to act on it. SIGNATURE DATE Information about fees associated with ReliaCard may be found at the Oregon Child Support Program website at www. OregonChildSupport. gov If you have any questions about this form please contact 1-800-850-0228 or visit the Oregon Child Support Program website at www. OregonChildSupport. gov Page 1 of 1 ReliaCard Enrollment/Authorization Form CSF 08 0700B New 04/13/10. Print Reset ReliaCard OREGON ELECTRONIC DISTRIBUTION ENROLLMENT/AUTHORIZATION FORM Send completed authorization to DOJ / DCS P. O. Box 14320 Salem OR 97309 OR Fax to 503 986-2416 Required Fields. Incomplete Authorizations may be returned to you causing a delay in your request. O. Box 14320 Salem OR 97309 OR Fax to 503 986-2416 Required Fields. Incomplete Authorizations may be returned to you causing a delay in your request. PLEASE PRINT CLEARLY IN BLACK OR BLUE INK Applications completed with red ink or pencil will be returned* PERSONAL INFORMATION CSP Case Number s Include all Oregon CSP case numbers you want deposited into this ReliaCard account.

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