Colorado Family Support Registry Internet Payment Website

smiONE™ DEBIT CARD APPLICATION

SECTION A - PAYEE INFORMATION NAME First * Middle Last * ADDRESS (PO Box or Street Address) * Apt. No. CITY * STATE/PROVINCE * -- US - Alabama US - Alaska US - American Samoa US - Arizona US - Arkansas US - Armed Forces - Other US - Armed Forces Americas US - Armed Forces Pacific US - California US - Colorado US - Connecticut US - Delaware US - District of Columbia US - Federated States of Micronesia US - Florida US - Georgia US - Guam US - Hawaii US - Idaho US - Illinois US - Indiana US - Iowa US - Kansas US - Kentucky US - Louisiana US - Maine US - Marshall Islands US - Maryland US - Massachusetts US - Michigan US - Minnesota US - Mississippi US - Missouri US - Montana US - Nebraska US - Nevada US - New Hampshire US - New Jersey US - New Mexico US - New York US - North Carolina US - North Dakota US - Northern Mariana Islands US - Ohio US - Oklahoma US - Oregon US - Palau US - Pennsylvania US - Puerto Rico US - Rhode Island US - South Carolina US - South Dakota US - Tennessee US - Texas US - U.S. Minor Outlying Islands US - Utah US - Vermont US - Virgin Islands US - Virginia US - Washington US - West Virginia US - Wisconsin US - Wyoming CA - Alberta CA - British Columbia CA - Manitoba CA - New Brunswick CA - Newfoundland and Labrador CA - Northwest Territories CA - Nova Scotia CA - Nunavut CA - Ontario CA - Prince Edward Island CA - Quebec CA - Saskatchewan CA - Yukon AU - Australia CA - Canada CZ - Czech Republic SV - El Salvador FI - Finland DE - Germany HU - Hungary IE - Ireland MX - Mexico NL - Netherlands NZ - New Zealand NO - Norway PL - Poland SK - Slovak Republic SE - Sweden CH - Switzerland GB - United Kingdom   ZIP *   - COUNTRY * Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia, Plurinational State of Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Curatao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland Former Czechoslovakia Former USSR France France (European Territories) French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Great Britain Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia, the former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles Neutral Zone New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory, Occupied Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint BarthTlemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, Province of China Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela, Bolivarian Republic of Viet Nam Virgin Islands (USA) Virgin Islands, British Wallis and Futuna Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe 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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