DEBIT CARD AUTHORIZATION
Michigan Department of Health and Human Services
Michigan State Disbursement Unit
Name (Last, First, Middle) (Print)
Home Telephone Number	Work Telephone Number	Date of Birth
Current/New Address (Number, Street, Apt. Number, City, State, Zip Code, Country (if not US))
Social Security Number	Case ID or Court Case (Docket) Number
(Identify one case number, but multiple cases may be paid in a single deposit.)
Number	County
I authorize the State of Michigan to deposit all support-related payments due to me onto a debit card.
Sign Here	Date
Mail or fax this form to: MiSDU Attn: Debit Card PO Box 30354 Lansing, MI 48909-7854 FAX: 517-318-4697
Note: The debit card will not be an interest-bearing account, and no interest will accumulate from money applied to the debit card.
The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, gender identification or expression, sexual orientation, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.