Form Ac 2772 - Direct Deposit Of Salary Enrollment/change/cancellation Form

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AC 2772 (Rev. 9/04)
OSC - DIRECT DEPOSIT OF SALARY ENROLLMENT/CHANGE/CANCELLATION FORM
Section A: Personal Information
NAME (LAST, FIRST, MI)______________________________________________
WORK PHONE # (____)______________
SOCIAL SECURITY #
___ ___ ___ - ___ ___ - ___ ___ ___ ___
AGENCY/DEPT CODE ___ ___ ___ ___ ___
Add
Chg
Can
Name of
Account #
Amount or %
Section B: Account Type
(√)
(√)
(√)
(√)
(√)
(√)
(√)
(√)
(√)
(√)
(√)
(√)
(√)
(√)
(√)
Financial Institution
or Excess
1.
Savings
Checking
2.
Savings
Checking
3.
Savings
Checking
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
Savings
Checking
Depositor’s Account Number (EFT Format)
Routing Number
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 sho wn above in accordance with P art 102 of the Ne w York State Comptroller’s Rules and Regulations and to be bound by such rules.
Salary credited to the above account will be a vailable to the depositor on pay day.
Date
Print or Type Representative’s Name
Signature of Representative
Telephone Number
2. NAME OF FINANCIAL INSTITUTION__________________________________Account Type
Sa vings
Chec king
Depositor’s Account Number (EFT Format)
Routing Number
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 sho wn above in accordance with P art 102 of the Ne w York State Comptroller’s Rules and Regulations and to be bound by such rules.
Salary credited to the abo ve account will be a vailable to the depositor on pay day.
Print or Type Representative’s Name
Signature of Representative
Telephone Number
Date
3. NAME OF FINANCIAL INSTITUTION__________________________________Account Type
Savings
Chec king
Depositor’s Account Number (EFT Format)
Routing Number
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 sho wn above in accordance with P art 102 of the New York State Comptroller’s Rules and Regulations and to be bound by such rules.
Salary credited to the abo ve account will be a vailable to the depositor on pay day.
Signature of Representative
Telephone Number
Date
Print or Type Representative’s Name
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 an y, 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_________________

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