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Colorado Family Support Registry Internet Payment Website

smiONE™ DEBIT CARD APPLICATION
SECTION A - PAYEE INFORMATION
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NAME
First *

Middle

Last *
ADDRESS (PO Box or Street Address) *


Apt. No.
CITY *
STATE/PROVINCE *
  ZIP *
  -
COUNTRY *
FSR#* Enter your ten-digit FSR account number including leading zeros. If you have multiple FSR numbers, just enter one. Your application will apply to all of your FSR numbers.
   
SOC SEC # * (No Dashes)
TELEPHONE # (Incl. Area Code)
() -
SECTION B - DEBIT CARD AUTHORIZATION
By signing this form, I authorize the Division of Child Support Services (DCSS) to share information with SMI Card Services, LLC (smiONE™) for the purpose of establishing a smiONE™ Visa Prepaid Card account for me and to deposit my child support payments to my card account. This authorization cancels and replaces any direct deposit agreement I currently have in place with the DCSS. Upon authorization of my account with SMI Card Services, LLC, I agree to be bound by the Cardholder Agreement that I will receive with my card. This authorization will remain in effect until cancelled by me in writing to the Family Support Registry.

   
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