Form Ac 2772 - Direct Deposit Of Salary Enrollment/change/cancellation Form (Page 2 of 2) in pdf

AC 2772 (Rev. 4)

Reverse Side

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.

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.

AUTHORIZATION FOR RECOVERY: By signing this form, the employee and each joint tenant, if any, each

consent to allow the Town, 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 Town from utilizing any other lawful means to retrieve salary payments to which the

employee is not entitled.

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 Town 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 Town. The Town may cancel an

employee’s direct deposits when internal control policies would be compromised by this form of salary payment.

NFORMATION

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 Program of the

, New York, 1

. Telephone Number: (

)

Form Ac 2772 - Direct Deposit Of Salary Enrollment/change/cancellation Form Page 2

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