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INSTRUCTIONS: ARIZONA DES/DCYF ELECTRONIC FUNDS TRANSFER AUTHORIZATION AGREEMENT (Form ACY-1246A)

An Arizona provider of or facility for child care may choose to receive supplemental funds from the Department of Economic Security's Division of Children, Youth And Families via direct deposit. This is done by filing a form ACY-1246A. This document can be obtained from the website maintained by the Arizona Department of Economic Security.

Arizona DES/DCYF Electronic Funds Transfer Authorization Agreement ACY-1246A Step 1: In the first blank box, enter the name of the provider or facility.

Arizona DES/DCYF Electronic Funds Transfer Authorization Agreement ACY-1246A Step 2: In the second blank box, enter the provider ID number if applicable.

Arizona DES/DCYF Electronic Funds Transfer Authorization Agreement ACY-1246A Step 3: in the third blank box, enter the provider suffix if applicable.

Arizona DES/DCYF Electronic Funds Transfer Authorization Agreement ACY-1246A Step 4: In the fourth blank box, enter the facility ID if applicable.

Arizona DES/DCYF Electronic Funds Transfer Authorization Agreement ACY-1246A Step 5: In the fifth blank box, enter your email addres.

Arizona DES/DCYF Electronic Funds Transfer Authorization Agreement ACY-1246A Step 6: In the sixth blank box, indicate whether this authorization agreement is new, documents a change, or requests a cancellation.

Arizona DES/DCYF Electronic Funds Transfer Authorization Agreement ACY-1246A Step 7: In the seventh blank box, enter the date on which you wish for this to become effective.

Arizona DES/DCYF Electronic Funds Transfer Authorization Agreement ACY-1246A Step 8: In the eight blank box, enter your daytime telephone number.

Arizona DES/DCYF Electronic Funds Transfer Authorization Agreement ACY-1246A Step 9: In the ninth blank box, enter the name of your financial institution.

Arizona DES/DCYF Electronic Funds Transfer Authorization Agreement ACY-1246A Step 10: In the tenth blank box, enter your account number.

Arizona DES/DCYF Electronic Funds Transfer Authorization Agreement ACY-1246A Step 11: In the eleventh blank box, indicate with a check mark whether this is a checking or savings account.

Arizona DES/DCYF Electronic Funds Transfer Authorization Agreement ACY-1246A Step 12: In the twelfth blank box, enter your routing transit number.

Arizona DES/DCYF Electronic Funds Transfer Authorization Agreement ACY-1246A Step 13: In the thirteenth blank box, indicate whether this bank account is solely yours, joint or other.`

Arizona DES/DCYF Electronic Funds Transfer Authorization Agreement ACY-1246A Step 14: Sign and date the form.