Form 74-158 - Employee Direct Deposit Authorization - 2009
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274-158
For Comptroller’s use only
(Rev.1-07/9)
CLEAR ALL FIELDS
EMPLOYEE DIRECT DEPOSIT AUTHORIZATION
INSTRUCTIONS
• Use only BLUE or BLACK ink.
• Check all appropriate box(es).
• Alterations must be initialed.
• For further instructions, see the back of this form.
TRANSACTION TYPE
New setup
(Sections 2, 3 & 4)
Change financial institution
(Sections 2, 3 & 4)
Cancellation
(Sections 2 & 3)
Change account number
(Sections 2, 3 & 4)
Interagency transfer
(Sections 2, 3 & 4)
Change account type
(Sections 2, 3 & 4)
PAYEE IDENTIFICATION
1. Social Security number
2. Mail code (If not known, will be
completed by Paying State Agency)
3. Name
4. Business phone number
(
)
5. Mailing address
6. City
7. State
8. ZIP code
AUTHORIZATION FOR SETUP, CHANGES OR CANCELLATION
9. I authorize the Comptroller of Public Accounts to deposit my payments from the state of Texas to my financial institution electronically. I further
understand that the Comptroller of Public Accounts will reverse any payments made to my account in error.
I also agree to comply with the National Automated Clearing House Association's rules and the Texas Comptroller of Public Accounts' rules for
electronic payments at all times.
10. Authorized signature
11. Printed name
12. Date
FINANCIAL INSTITUTION (Completion by financial institution is recommended.)
13. Name
14. City
15. State
YES
16. Routing transit number
17. Customer account number
(Dashes required
)
18. Type of account
Checking
Savings
19. Representative name (Please print)
20. Title
21. Representative signature (Optional)
22. Phone number
23. Date
(
)
CANCELLATION BY AGENCY
24. Reason
25. Date
PAYING STATE AGENCY
26. Signature
27. Printed name
28. Agency name
29. Agency number
30. Comments
31. Phone number
32. Date
(
)
Note: An employee can receive email or fax notifications providing (1) business day advance notice of their travel payment posting
to the direct deposit account.
To enroll in this free service complete the Advance Payment Notification Authorization, Form 74-193, available on the Internet at:
For additonal information or assistance, please contact the Claims Division by:
E-mail: claims.pin@cpa.state.tx.us
Phone: 512/936-8138 in Austin or 800/531-5441 Ext. 6-8138 toll free
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