Louisiana Early Steps
Central Finance Office
Direct Deposit Authorization/Change Request
LADHHR EFT (09-2004)
The Louisiana Early Steps program provides a safe, easy, and trouble-free way for you to receive your
payments.* Direct Deposit places your payments electronically into your checking account instead of
having to wait to receive your check by mail.
Authorization/Change
I hereby authorize the Louisiana Early Intervention-Central Finance Office, hereinafter called DHHR-CFO,
to initiate credit entries, and debit entries for any erroneous credit, to the following bank account (checking
accounts only).**
Payee Information:
Payee Name:____________________________________ FEIN/Social Security Number:______________
Payee Address:__________________________________
City:_________________ State:_________ Zip: _____________
Payee Telephone Number: ________________________________
Financial Institution Name: ______________________________________________
Account Information: Attach a voided or canceled check. A copy is acceptable.
Name on Account:_____________________________________________________
This authority is to remain in full force until DHHR-CFO has received notification from me of its
termination in such time and in such manner as to afford DHHR-CFO and Depository a reasonable
opportunity to act on it.
Furthermore, It is agreed that this agreement can be terminated by DHHR-CFO with reasonable notification
to the party.
Authorized Name:_____________________
Signature:___________________________ Date: _________________________
Please Return Completed Form and Documentation to:
Mail: Attn: Provider Enrollment FAX: 1-913-888-6683
Louisiana Early Intervention – Central Finance Office
P/O Box 29134
Shawnee Mission, KS 66201-9134
For CFO Use Only Date Received Date Entered Entered by Test Complete date
* If you elect to receive payments electronically, all funds must be designated to one account.
* *Negative balances at month end will not be debited from your checking account. The negative amount
will be deducted from future payments.
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