Crisis & Intake:
1-855-687-1868

Direct Deposit Enrollment / Change Form

Direct Deposit request for(Required)

Personal Information

Address(Required)

Financial Institution Information

Type of Account(Required)

Authorization

I authorize BWSS, and my financial institution named above to deposit automatically my payments to my account mentioned here. This authorization includes my consent to reverse any entries made in error.
Date(Required)
Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.
This field is for validation purposes and should be left unchanged.