IHSS Direct Deposit Authorization Form

Information you will need

• What’s the payee's address?
• What's the payee's city?
• What's the payee's state?
• What's the payee's ZIP code?
• What’s the account type?
• What's the purpose of this deposit form?
• What’s the case number?
• What’s the provider number?
• What’s the routing number?
• What’s the bank account number?
• What’s the payee's full name?
• What’s the name of the bank?

Completed by the provider and the recipient.