Indiana Direct Deposit Form 2

Reset Form
AUDITOR OF STATE
PAYROLL DIRECT DEPOSIT
State Form 43591 (R12 / 10-09)
Approved by Auditor of State, 2009
Approved by State Board of Accounts, 2009
INFORMATION AND INSTRUCTIONS:
1. You may elect up to two (2) direct deposit accounts and must have a primary direct deposit account in order to have a secondary direct deposit account.
2. If you choose to only have one (1) direct deposit account then you will only need to fill out the PRIMARY DIRECT DEPOSIT form below.
3. If you choose to have two (2) direct deposit accounts you will need to fill out both the primary and secondary forms and you must enter a dollar amount
or a percentage on the secondary direct deposit form.
4. If you already have a primary direct deposit account on file with the Auditor's Office, then you only need to complete the secondary direct deposit form.
5. Fill out the employee's portion, attach a voided check, or have your financial institution fill out its portion.
6. Check the type of account - checking or savings.
7 Sign and date the form(s) and return the entire sheet to: Auditor of State
7.
State, 200 W
W. Washington St
St., Rm
Rm. 144
144, Indianapolis
Indianapolis, IN 46204
46204.
8. In the event that you already have a second direct deposit and are only c hanging the dollar or percentage amount, it is not necessary for the financial
institution to sign this form.
Please check this box if you receive your payroll via direct deposit at a U.S. bank and then have the entire payroll amount automatically
forwarded to a bank in another country.
PRIMARY DIRECT DEPOSIT
Name (last,
(last first
first, middle initial)
Check one
Add
Agency name or level 2
Change
Address (number and street, city, state, and ZIP code)
Social Security Number
THIS SECTION IS TO BE FILLED IN BY THE FINANCIAL INSTITUTION IN WHICH THE EMPLOYEE'S ACCOUNT IS LOCATED.
NOTE: The Financial Institution must be a member of the Automated Clearing House System and must be able to handle direct deposits by electronic transfer.
ABA transit-routing number (9 digits)
Employee's depository account number
Type of account (check one)
Checking
Name of financial institution
Savings
Address of financial institution (city, state, and ZIP code)
Signature of officer
Title of officer
Date signed (month, day, year)
THIS SECTION TO BE READ AND SIGNED BY THE EMPLOYEE
I hereby authorize the Auditor of State to deduct from my pay each payday an amount equal to my net pay to be electronically transferred to my account
described above. I have read the conditions printed on both sides of this form and agree to them.
Signature of employee
Date signed (month,
(month day
day, year)
SECONDARY DIRECT DEPOSIT
Name (last, first, middle initial)
Check one
Add
Address (number and street, city, state, and ZIP code)
Amount
$
Agency name or level 2
Change
Percent
or
Social Security Number
%
THIS SECTION IS TO BE FILLED IN BY THE FINANCIAL INSTITUTION IN WHICH THE EMPLOYEE'S ACCOUNT IS LOCATED.
NOTE: The Financial Institution must be a member of the Automated Clearing House System and must be able to handle direct deposits by electronic transfer.
ABA transit-routing number (9 digits)
Employee's depository account number
Type of account (check one)
Checking
Name of financial institution
Signature of officer
Savings
Address of financial institution (city, state, and ZIP code)
Title of officer
Date signed (month, day, year)
THIS SECTION TO BE READ AND SIGNED BY THE EMPLOYEE
I hereby authorize the Auditor of State to deduct from my pay each payday the amount or percent indicated on this form to be electronically transferred to my
account described above. I have read the conditions printed on both sides of this form and agree to them.
Signature of employee
Date signed (month, day, year)
DIRECT
DEPOSIT
For the employees
p y
of the State of Indiana.
EMPLOYEE CONDITIONS:
Signing and submitting this form indicates that you understand and agree to the terms and
conditions stated herein.
I authorize the Auditor of State to directly deposit my net pay by electronic transfer through the
initiation of credit entries to the financial institution identified by me on this form under “Primary
Direct Deposit”, and to initiate debit entries to recover any erroneous deposits to my account, if
necessary.
If applicable, I authorize the Auditor of State to directly deposit a specific dollar amount or
percentage of my net pay by electronic transfer through the initiation of credit entries to the
fi
financial
i l institution
i tit ti identified
id tifi d by
b me on this
thi form
f
under
d “Secondary
“S
d
Direct
Di t Deposit”,
D
it” and
d to
t initiate
i iti t
debit entries to recover any erroneous deposits to my account, if necessary.
I understand that if I elect to transfer a specific dollar amount rather than a percentage of my net
pay as a Secondary Direct Deposit, and my net pay remaining after my Primary Direct Deposit in
any pay cycle is less than the amount designated for Secondary Direct Deposit, all of my net pay
posted to my
y Primary
y Direct Deposit
p
account,, with none p
posted to my
y Secondary
y Direct
will be p
Deposit account.
This authority for Primary Direct Deposit and, if applicable, Secondary Direct Deposit, shall
remain in full force and effect until the Auditor of State has received written notification from me
of its termination at a time and in a manner that affords the Auditor of State and the financial
institution(s) named on the front of this form a reasonable opportunity to act upon the notification.
I understand that my failure to notify the Auditor of State of any change in my financial
institution(s) or depository account(s) may result in a delay in receiving my pay.
I understand that upon termination of my employment with the State, my final pay shall be by
Payroll Warrant, and not by direct deposit.