In-Home Supportive Services Provider Direct Deposit Enrollment /change /cancellation Form (California) Page 2
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1
2IN-HOME SUPPORTIVE SERVICES
PROVIDER DIRECT DEPOSIT ENROLLMENT INSTRUCTIONS
*PLEASE READ CAREFULLY*
You will need the following information to complete the Direct Deposit Enrollment Form:
1. The name of your Bank.
2. The Bank Routing Number
3. Your Checking or Savings Account Number. If you need help identifying this information please ask your Bank
for assistance.
CHECK APPROPRIATE BOX
Please check the box to tell us what you want to do. Check the Box: NEW to enroll in direct deposit; CHANGE to change
your bank account; and CANCEL to cancel direct deposit.
Check the box to tell us whether you want your paycheck deposited in your Checking or Savings account.
IDENTIFICATION INFORMATION
Provide your Recipient and Provider number. You will find the recipient and provider numbers on your IHSS Statement of
Earnings (pay stub).
BANKING INFORMATION
Provide the information requested on the form. You may find the bank information you will need to complete the enrollment
form on your personal checks or your bank may assist you. Below is an example of a check and where to find the
necessary information.
Check Example:
Your Name
Check NO. 4444
Pay to the Order of _________________________________
I112145678 I:
5765432109812
4444
Routing No.
Your Acct. No.
Ck. No.
If you prefer to have your money deposited into your savings account, please contact your bank for assistance.
SIGN THE FORM
Your signature authorizing Direct Deposit must be an ORIGINAL SIGNATURE, photocpies will not be accepted.
PROVIDE ALL REQUESTED INFORMATION
All information requested on the form must be provided. Incomplete forms will be returned. To enroll in Direct Deposit you
must complete all fields on an Enrollment/Change/Cancellation form.
IF YOU WORK FOR MULTIPLE RECIPIENTS
You must complete a separate Provider Enrollment/Change/Cancellation form for EACH Recipient with whom you are
employed. When you begin work for a new recipient you will need to complete a new form.
CHANGING OR CANCELLING YOUR DIRECT DEPOSIT
Your Direct Deposit will continue to be deposited into the bank account you have chosen until you request a change. If you
wish to change or cancel your Direct Deposit authorization for any recipient for whom you work, you must submit an
Enrollment/Change/Cancellation form with a check next to the box for Change or Cancel. You may access our website at
to download additional forms or contact the Direct Deposit Help desk toll free at (866) 376-7066.
Please send your COMPLETED Enrollment/Change/Cancellation Form to:
DIRECT DEPOSIT PROCESSING CENTER
P.O. BOX 1600
RANCHO CORDOVA, CA 95741-1600
SOC 829 (3/08)
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