Fillable Form 1.: IN-HOME SUPPORTIVE SERVICES PROGRAM DIRECT DEPOSIT (California)

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Form 1.: IN-HOME SUPPORTIVE SERVICES PROGRAM DIRECT DEPOSIT (California)

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Country of origin: US
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES PROGRAM
DIRECT DEPOSIT
ENROLLMENT/CHANGE/CANCELLATION FORM
To elect, change or cancel Direct Deposit, please read the attached instructions and complete all of the information requested.
A separate form must be completed for each type of enrollment action.
You are not eligible for direct deposit if you will send 100% of the funds deposited to your bank to another bank outside the US.
PLEASE TYPE OR PRINT CLEARLY USING A BALL POINT PEN.
TYPE OF ACTION
1.
■■
NEW
2. ■■ CHANGE
3. ■■ CANCEL
(TO BE COMPLETED BY THE RECIPIENT/GUARDIAN/CONSERVATOR)
A. RECIPIENT NUMBER
B. NAME OF PAYEE (LAST, FIRST, MIDDLE) TELEPHONE #
ADDRESS (STREET, ROUTE, P.O. BOX)
( )
( )
CITY STATE ZIP CODE
C. NAME OF GUARDIAN/CONSERVATOR (LAST, FIRST, MIDDLE)
TELEPHONE #
ADDRESS (STREET, ROUTE, P.O. BOX) CITY STATE
ZIP CODE
D. PAYEE SOCIAL SECURITY #
E. TYPE OF DEPOSITOR ACCOUNT (CHECK ONE)
Checking Savings
F. NAME AND ADDRESS OF FINANCIAL INSTITUTION
G. ROUTING #
H. DEPOSITOR ACCOUNT #
I. BRANCH NAME & NUMBER
J. CHECK APPROPRIATE BOX
I hereby authorize the County Welfare office to directly deposit my monthly advance payments.
I hereby authorize the County Welfare office to change my Direct Deposit.
I hereby cancel my Direct Deposit authorization.
K. SIGNATURE OF PAYEE/GUARDIAN/CONSERVATOR DATE
White - County copy Yellow - Payee copy
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SOC 404 (10/11)
This is a form for direct deposit enrollment/change/
cancella
tion, instructions are included on page 2 and
3. However, you can just go through the form fields in
order, as they have individual instructions.
123123
123
click to sign
signature
click to edit
STATE OF CALIFORNIA
IHSS PROGRAM
Dear IHSS Recipient:
As an alternative to receiving your monthly In-Home Supportive Services (IHSS) advance pay warrant by mail, the State
Department of Social Services (SDSS) is offering you the option of having your advance payment electronically transferred to a
financial institution (Bank, Savings and Loan, or Credit Union) of your choice. Direct Deposit through Electronic Fund Transfer
(EFT) is limited to those financial institutions by law. Direct Deposit is optional. If you choose to continue receiving your
advance pay by mail, you do not need to complete the attached form or take any action.
WHAT IS DIRECT DEPOSIT THROUGH EFT?
With Direct Deposit through EFT, your advance payment is electronically transferred to the financial institution of your choice.
You will not receive a warrant through the mail. Instead, every month you will receive a deposit stub, by mail from the State
Controller’s Office, with information about your direct deposit and tax deductions. By the time you receive the deposit stub,
your money will already be waiting in your account. This will save you a trip to the bank.
WHO IS ELIGIBLE FOR DIRECT DEPOSIT?
You are eligible for Direct Deposit if you have been an IHSS recipient for one year, receiving your payment in advance and you
hire and pay your service providers.
You are not eligible for direct deposit if you will send 100% of the funds deposited to your bank to another bank outside the US.
ENROLLMENT INSTRUCTIONS:
* PLEASE READ CAREFULLY *
WHEN TO USE THE DIRECT DEPOSIT ENROLLMENT FORM SOC 404.
To enroll in Direct Deposit, complete the Type of Action section and, sections A through K on the attached form (SOC 404).
1. To sign up as a new enrollee.
2. To change Direct Deposit from checking to savings or vice versa.
3. To change Direct Deposit from one financial institution to another.
4. To change depositor account number within a financial institution.
5.
To cancel Direct Deposit.
WHEN WILL MY FIRST DIRECT DEPOSIT TRANSACTION BE CREDITED TO MY ACCOUNT?
Your first transaction may occur from 60 to 90 days after your request is received by your County Welfare Office. The posting
date of your deposit is the first day of the month, unless it is a weekend or holiday, then it is the first working day following the
weekend or holiday.
IF THERE ARE ANY PROBLEMS WITH THE DIRECT DEPOSIT INFORMATION, IT CAN DELAY RECEIVING YOUR
MONEY BY AS MUCH AS 14 DAYS.
INSTRUCTIONS CONTINUED ON BACK
SOC 404 (10/11)
ENROLLMENT INSTRUCTIONS.
1. To enroll in Direct Deposit, complete the Type of Action section and, sections A through K on the attached
form (SOC 404).
2. A separate form must be completed for each type of action requested.
Example 1
FINANCIAL INSTITUTION CHECK NO. 4444
HOMETOWN, USA
PAY TO THE ORDER OF
I:112145678 I: 5765432109812 4444
Routing No. Dep. Acct. No. Ck. No.
{
{
{
Example 2
FINANCIAL INSTITUTION CHECK NO. 4444
HOMETOWN, USA
PAY TO THE ORDER OF
I:112145678 I: 4444 8765432109812
Routing No. Ck. No. Dep. Acct. No.
{
{
{
3. Please verify your depositor account number and routing number with your financial institution.
4. Attach your voided personal check to the upper left portion of the back of the white copy of the enrollment form if
you are depositing your funds into your checking account. This will aid in verifying your depositor account
number and routing number.
5. For savings account - secure your routing number and depositor number from your financial institution.
SEND THE WHITE COPY OF THE COMPLETED ENROLLMENT FORM TO YOUR COUNTY WELFARE OFFICE AND
RETAIN THE YELLOW COPY FOR YOUR RECORDS.
CHANGING FINANCIAL INSTITUTIONS OR DEPOSITOR ACCOUNTS.
Your Direct Deposit will continue to be deposited into your designated account at your financial institution until the County
Welfare Office is notified that you wish to redesignate your account and/or your financial institution. To redesignate, complete
and submit a new enrollment form with the new information.
DO NOT CLOSE YOUR OLD ACCOUNT UNTIL YOUR FIRST PAYMENT IS DEPOSITED INTO YOUR NEWLY
DESIGNATED ACCOUNT AND/OR FINANCIAL INSTITUTION.
CANCELLATION.
The agreement represented by this authorization remains in effect until cancelled by you by written notice to your County
Welfare Office. In the event of your death or legal incapacity, it is the responsibility of your estate to notify your County Welfare
Office by written notice. It is your responsibility or the responsibility of your estate to notify the receiving financial institution that
the authorization has been cancelled. If you become ineligible for advance payment, your Direct Deposit will be cancelled
immediately.
SOC 404 (10/11)
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Form 1.: IN-HOME SUPPORTIVE SERVICES PROGRAM DIRECT DEPOSIT (California)

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Completed 15 February 2021

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