Direct Deposit Form

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AC 2772 (Rev. 6/04)
OSC - DIRECT DEPOSIT OF SALARY ENROLLMENT/CHANGE/CANCELLATION FORM
Section A: Personal Information
NAME (LAST, FIRST, MI)______________________________________________
SOCIAL SECURITY #
___ ___ ___ - ___ ___ - ___ ___ ___ ___
Section B: Account Type
1.
Savings
Checking
2.
Savings
Checking
3.
Savings
Checking
Add
(√)
Chg
(√)
Can
(√)
WORK PHONE # (____)______________
AGENCY/DEPT CODE ___ ___ ___ ___ ___
Name of
Financial Institution
Account #
Amount or %
or Excess
If more than a total of three accounts is desired, complete additional forms as appropriate. Up to seven fixed amount or percent
deposits may be processed as well as one excess (net pay) deposit. The employee and any joint account holders must sign in
Section D.
Section C: Must be completed by your Financial Institution if directing funds into a savings account or if a voided personal
check is not attached. The employee’s name MUST appear on the account.
1. NAME OF FINANCIAL INSTITUTION_________________________________Account Type
Depositor’s Account Number (EFT Format)
Savings
Routing Number
Checking
Check Digit
_______________________________________________________________
___ ___ ___ ___ ___ ___ ___ ___
_______
As a representative of the above named Financial Institution, I certify that this institution is ACH capable and agree to receive and deposit the salary
to the account shown above in accordance with Part 102 of the New York State Comptroller’s Rules and Regulations and to be bound by such rules.
Salary credited to the above account will be available to the depositor on pay day.
Print or Type Representative’s Name
Signature of Representative
Telephone Number
2. NAME OF FINANCIAL INSTITUTION__________________________________Account Type
Depositor’s Account Number (EFT Format)
Savings
Routing Number
Date
Checking
Check Digit
_______________________________________________________________
___ ___ ___ ___ ___ ___ ___ ___
_______
As a representative of the above named Financial Institution, I certify that this institution is ACH capable and agree to receive and deposit the salary
to the account shown above in accordance with Part 102 of the New York State Comptroller’s Rules and Regulations and to be bound by such rules.
Salary credited to the above account will be available to the depositor on pay day.
Print or Type Representative’s Name
Signature of Representative
Telephone Number
3. NAME OF FINANCIAL INSTITUTION__________________________________Account Type
Depositor’s Account Number (EFT Format)
Savings
Routing Number
Date
Checking
Check Digit
_______________________________________________________________
___ ___ ___ ___ ___ ___ ___ ___
_______
As a representative of the above named Financial Institution, I certify that this institution is ACH capable and agree to receive and deposit the salary
to the account shown above in accordance with Part 102 of the New York State Comptroller’s Rules and Regulations and to be bound by such rules.
Salary credited to the above account will be available to the depositor on pay day.
Print or Type Representative’s Name
Signature of Representative
Telephone Number
Date
Section D: Employee/Joint Account Holders Certification: I certify that I read and understand the instructions to this form,
including the authorization for recovery. In signing this form, I authorize my salary payment to be sent to the Financial Institution(s)
named to be deposited into the designated account. The joint account holder for section C-1, C-2 and C-3, if any, must sign on the
corresponding line.
Employee _______________________________________________________________________Date_________________
Joint Holder Account C-1 ___________________________________________________________Date_________________
Joint Holder Account C-2 ___________________________________________________________Date_________________
Joint Holder Account C-3 ___________________________________________________________Date_________________
AC 2772 (Rev. 6/04)
Reverse Side
INFORMATION
The information on this form is required under the New York State Comptroller’s Rules and Regulations (2 NYCRR 102). The
information supplied by the employee will be provided only to the designated financial institution(s) and/or their agent(s) for the purpose
of processing payments. Failure to provide the requested information may delay or prevent the receipt of payments through the Direct
Deposit/Electronic Funds Transfer Program of the Bureau of State Payroll Services, NYS Office of the State Comptroller, 110 State
Street, Albany, New York, 12236. Telephone Number: (518) 402-4190.
AUTHORIZATION FOR RECOVERY: By signing this form, the employee and each joint tenant, if any, each
consent to allow the State, through the financial institution, to debit the account in order to recover any salary to
which the employee was not entitled which was deposited to the account in error or by mistake. This means of
recovery shall not prevent the State from utilizing any other lawful means to retrieve salary payments to which the
employee is not entitled.
MULTIPLE DIRECT DEPOSITS ARE AVAILABLE: Employees may choose up to seven fixed amount or percent
direct deposits, as well as one net pay or excess pay direct deposit after all fixed amount or percent direct deposits.
This form accommodates up to three accounts. For more than three accounts, use additional form(s) when necessary.
INSTRUCTIONS: Employee must complete Sections A, B and D for each ADDED, CHANGED OR CANCELED
account. Forward the completed form to the payroll or personnel office of the State agency/department identified
in Section A. This form is a legal document and cannot be altered by the agency, employee or financial institution.
If there are any changes, the employee must complete a new form.
Checking Accounts - Attach a voided check or have Section C completed by your Financial Institution.
Savings Accounts - Section C must be completed by your Financial Institution.
Account # is obtained from a personal check or the Financial Institution.
Enter the specific Amount when a fixed amount is being deposited (may include cents, e.g. $100.25) or enter the
specific percent when a portion of the check is being deposited (must be indicated as a full percentage, e.g. 50%).
Write the word Excess when the remainder of monies is to be deposited after all other distributions.
CHANGES: Employees may add, change or cancel a money or percent amount by completing a new Direct
Deposit of Salary Enrollment/Change Form. New fixed amount or percent direct deposits will be assigned a lesser
priority than existing fixed amount or percent direct deposits. For example, if an employee’s pay is not sufficient
to cover all direct deposits, the most recently designated direct deposit(s) will not be taken. To change direct
deposit priorities, please contact your agency payroll or personnel officer. Financial institution changes may take
up to two payroll periods. Employees should maintain accounts canceled and replaced by new accounts until the
new transaction is complete. If canceled accounts are not temporarily maintained until the new account receives
the employee’s direct deposit transaction, employees may experience a delay in payments.
CANCELLATIONS: The agreement represented by this authorization remains in effect until canceled by the
employee or the financial institution. To cancel, the employee must complete an Enrollment/Change Form that
contains all account data information as required in Sections A, B and D for the transaction to be canceled. The
agreement represented by this authorization may be canceled by the financial institution by providing the employee
and the State agency with a written notice 30 days in advance of the cancellation date. The financial institution
cannot cancel the authorization without notification to both the employee and the State agency. The State agency
may cancel an employee’s direct deposits when internal control policies would be compromised by this form of
salary payment.