Automatic Deposit Transmittal Form - Oklahoma Department Of Corrections
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1
2Official Use Only
State of Oklahoma
Department of Corrections
AUTOMATIC DEPOSIT TRANSMITTAL
This form is to be used by State and Higher Education Employees in communicating their direct deposit information.
Social Security
PS Employee ID:
Number:
Last Name
First Name
(limit to 15 characters)
:
(limit to 15 characters)
Date of Birth:
/
/
MM
DD
YYYY
I hereby authorize the State of Oklahoma, as per the Oklahoma State Employee’s Direct Deposit Act, 74:292.10 to:
PAYROLL – (Deposit my payroll warrant in my account as indicated below)
ADD
PAYROLL – (I understand that by terminating Direct Deposit for Payroll this will automatically terminate travel and
REMOVE
spending from my direct deposit)
SPENDING ACCOUNT – (HEALTH CARE, DEPENDENT CARE REIMBURSEMENT)
ADD/ REMOVE
ADD/ REMOVE
TRAVEL
If monies to which I am not entitled are deposited to my account, I authorize the State of Oklahoma to direct the financial institution to
return said funds. I understand the payroll date and frequency of payment currently being utilized by my employing agency will not be
affected by my decision to use Electronic Fund Transfer.
PayCard
ONLY ONE ACCOUNT MAY BE USED FOR DIRECT DEPOSIT
CHECKING
SAVINGS
Financial Institution
Name (Your Bank):
:
City
State:
This authority is to remain in full force and effect until: (A) I give my employer written notice using this form (OPM-73) to terminate this
direct deposit agreement. (B) I fail to utilize payroll direct deposit for 365 days, at which time this agreement will expire. (C) The event of
my death, at which time this agreement expires immediately, upon notification. This information is provided by me to facilitate my
.
personal banking needs and shall be considered personal and held in confidence
Home Mailing
Address:
City:
State:
ZIP:
Home Telephone
Work Telephone
Number:
Number:
Email:
Employing Agency:
Dept. of Corrections - Facility/Unit:
Signature:
Date:
/
/
I understand that while a change of enrollment is in process I may, in fact, receive a warrant instead of an electronic transfer.
If this is an initial enrollment or bank routing and/or account number change please attach a voided check or an official document from
your financial institution showing the financial institution’s routing number and your account number.
A signed form must be on file with the employer.
Paycard Option
Please mail the completed form to the address below.
Customer Service Phone
Oklahoma Department of Corrections
Number:
ATTACH CHECK HERE
ATTN: Personnel—Payroll Unit
3400 Martin Luther King Ave., P.O. Box 11400
1-866-444-4283
Oklahoma City, OK 73136-0400
HCM-73 (Revised 11/14/2013)
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