Child Care Assistance Program Direct Deposit

INSTRUCTIONS
COMPLETING AUTHORIZATION FOR DIRECT DEPOSIT FORM

1. Complete the Information on the Name and Address of the bank that will receive the child care payments. Make sure to tell us if this is a "Business" account or a "Personal" account.

2. Select Account Type. Will the funds be deposited to a checking or a savings account? Select one.

3. Information about you. You must print your name, DHS Provider ID (the 10- digit number that appears on your attendance sheet; starts with zeroes), a phone number where we can reach you.

4. Signature. You must sign the form. The form will be returned to you if not signed and this will delay your direct deposit.

5. Required Documents to attach to the form.

    a. For Checking Accounts--A Voided Check, if this is a new account or your checks don't have your name and address printed on them, YOU MUST get a letter from your bank with your name, address, account number and bank routing number. DO NOT SEND DEPOSIT SLIPS OR BANK STATEMENTS. THESE ARE NOT ACCEPTABLE.
    b. For Savings Accounts--A letter from your bank with your name, address, account number and bank routing number. DO NOT SEND DEPOSIT SLIPS OR BANK STATEMENTS. THESE ARE NOT ACCEPTABLE.

6. Business Checks. If you are a certified Family Provider with business checks showing just the name of your home daycare (for example "Mary's Little Lambs Home Daycare"), YOU MUST provide a letter from the bank to prove that you have signing rights to the account.

7. Once we receive your form and required documentation, it will take 2 payroll runs before you see your DHS payment deposited to your account.The first payroll you will receive a paper check; the next payroll your DHS payment will be deposited to your account.You will continue to receive a Provider Payment Report (previously known as the Vendor Payroll or "stub") listing all the children that were approved for payment.

-Click Here to Print the Instructions-

CCAP-5
REV: 01/07

Send this form to:

Department of Human Services
Office of Financial Management
Child Care Provider Direct Deposit
57 Howard Avenue, LP Bldg #57
Cranston, RI 02920
(401) 462-6868

AUTHORIZATION FOR DIRECT DEPOSIT

The Department of Human Services, Office of Financial Management is authorized to initiate Direct Deposit of my Child Care Provider Payments to my account at the Financial Institution below:

Financial Institution:

(bank or credit union)_________________________________________________________________

Branch Address:_____________________________________________________________________

                           _____________________________________________________________________

                           _____________________________________________________________________

City: ___________________________________ State: ___________________ Zip: _______________

Account Number:_______________________ [] Business [] Personal

PLEASE SELECT AN ACCOUNT TYPE

[] Checking Account**

ATTACH A VOIDED BLANK CHECK from the checking account to which the direct deposit will be made. Your name and current address must be printed on the check. If you cannot provide a proper voided check, you must provide a letter from your financial institution, which includes your name, address, bank routing number and account number. The letter must be on bank letterhead and signed by a bank representative. DO NOT SEND DEPOSIT SLIPS OR BANK STATEMENTS. Your name must appear on the account and the account must be with a United States financial institution.

[] Savings Account**

ATTACH A LETTER FROM YOUR FINANCIAL INSTITUTION with your name, address, bank routing number and account number. The letter must be on bank letterhead and signed by a bank representative. DO NOT SEND DEPOSIT SLIPS OR BANK STATEMENTS. Your name must appear on the account and the account must be with a United States financial institution.

**If the same payment has been deposited more than once into your account, child care will immediately correct the mistake and notify you of the removal of the duplicate funds from your account.

PLEASE COMPLETE INFORMATION BELOW

Your Name:_________________________________________________________________________

Your DHS Provider ID Number:__________________________________________________________

Your Phone Number:__________________________________________________________________

Your Signature:______________________________________ Date: ___________________________

Please complete this form and mail it to the address at the top.

-Click Here to Print the CCAP-5 Form-