Notice And Consent For Direct Deposit - New York State
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1Notice and Consent for Direct Deposit
Employer Information
Name: _____________________________________
Address: ___________________________________
Employee Work Location: __________________________ Phone Number: _______________________
Methods of Payment
As a New York State employer, we must can pay your wages in cash or check. This does not require
your approval. We may also pay your wages by direct deposit or payroll debit card. These forms of
payment require you to approve. If you do not approve, we will pay you in cash or check.
If you would like to receive your wages by direct deposit to a financial institution of your choice, please
read and sign below.
Direct Deposit Consent:
On this day I have been notified of my options of payment methods. I give consent to the above listed
employer to pay my wages through Direct Deposit to a financial institution that I have selected.
1. Bank Name: ______________________________________________________________________
City, State: _______________________________________________________________________
Routing Transit #: ______________________ Account Number: _____________________________
□ Checking □ Savings □ Other
I wish to deposit $________________ □ Entire Net Amount
2. Bank Name: ______________________________________________________________________
City, State: _______________________________________________________________________
Routing Transit #: ______________________ Account Number: _____________________________
□ Checking □ Savings □ Other
I wish to deposit $________________ □ Entire Net Amount
________________________________________
______________________________________
Print Employee Name
Employee Signature
_______________________________
Date
Please note that we must receive your written consent at least seven business days prior to paying
wages by direct deposit. You can also withdraw consent at anytime and discontinue your enrollment in
the payroll debit card payment method.
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