Direct Deposit Enrollment Form - Oklahoma Employment Security Commission printable pdf download

Oklahoma Employment Security Commission Direct Deposit Enrollment Form

YOU ARE CURRENTLY ENROLLED IN THE OKLAHOMA DEBIT MASTERCARD

CARD PROGRAM

If you would like to sign up for Direct Deposit, you must complete this form and return it to the address

below: Direct Deposit may add

hours for receipt of funds.

• To have your funds directly deposited in your bank account, you MUST attach a voided check, savings account deposit slip or a

letter from your bank on bank letterhead with your routing and account number. No handwritten infomation or temporary

checks are accepted.

• Staple or Tape your voided check or savings account deposit slip to this form.

• Your name MUST be pre-printed on the voided check or savings account deposit slip.

• We CANNOT deposit your funds into an account that is not located within the United States or its Territories (i.e. Puerto Rico;

U.S. Virgin Islands; American Samoa).

• Mail or Fax this completed form to:

Conduent for OESC Direct Deposit

Dept. SGS

Mustang Rd.

Yukon, OK

Fax Number:

REQUIRED INFORMATION FOR DIRECT DEPOSIT:

THIS FORM WILL BE REJECTED IF YOUR ACCOUNT INFORMATION IS NOT INCLUDED

Enrollee Information

First Name:_________________________ MI_____ Last Name_________________________

Social Security Number (SSN) ____ ____ ____- ____ ____ - ____ ____ ____ ___

Contact Telephone Number (

)________________________________

Account where I want my beneﬁts deposited

Bank or Financial Institution ________________________________________________________

Bank Address ______________________________________________________________________

______________________________________________________________________

Account Type (select one): ____ Checking

____ Savings

Do you intend to deposit funds into an account outside of the United States: ____ Yes ____ No

If Yes, please identify the Bank Country: ________________________________ (Note: We cannot send

funds to countries outside the U.S. or its Territories)

Bank Routing/Transit Number: ____ ____ ____ ____ ____ ____ ____ ____ ____

Account Number

(up to

digits): ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____

You can ﬁnd your bank information on your checks as shown below:

123456789

12 34567890

101

Routing/Transit Number

Account Number

I certify that I am eligible to receive payments from the Oklahoma Employment Security Commission (OESC). I authorize

the OESC to send my payments to the nancial institution named above to be deposited in the account indicated above.

This authorization will remain in force until Conduent receives noti cation asking for termination. Conduent shall have a

reasonable time to process the termination.

Signature: ______________________________________ Date: ________________________

Direct Deposit Enrollment Form - Oklahoma Employment Security Commission

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