Employee Direct Deposit Form - Oregon Department Of Administrative Services Page 2
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2State of Oregon Employee Direct Deposit Form
Employee ID #
Agency #
Name
Email Address
Work Phone #
Account information:
New
Cancel
Replace Net Pay Account
Replace Fixed Account and/or Amount
1. Bank Name/City/State:
Routing/Transit #
Account #
Checking
Savings
Non‐AccelaPay Card
Travel Reimbursements Dep. Amt.: $
or
Net amount
Account information:
New
Cancel
Replace Net Pay Account
Replace Fixed Account and/or Amount
2. Bank Name/City/State:
Routing/Transit #
Account #
Checking
Savings
Non‐AccelaPay Card
Travel Reimbursements Dep. Amt.: $
or
Net amount
Employee Authorization ‐ Important! Read and sign before submitting
I authorize the State of Oregon to deposit payments and make overpayment adjusting debits to my account. I have read and
understand the information contained in this form. I understand that direct deposit transactions must comply with U.S. and Oregon
laws. I authorize the State of Oregon to suspend direct deposit participation when overpayments may occur or recur (Ref. OAM
45.37.00).
International transaction certification – I certify that the entire amount of my direct deposit is NOT ultimately deposited in a financial
institution outside the United States.
Electronic Deposit/ePaystub (OAR. 125‐015‐0200):
I have elected net pay direct deposit of my wages and agree to access my paystub electronically.
I elect not to participate in net pay direct deposit of my wages and will receive a paper check and paper stub.
I meet one of the exception criteria listed in Oregon Administrative Rule 125‐015‐0200 and am choosing to receive my pay
through direct deposit and not participate in ePaystub (this option requires payroll and/or *human resources authorization).
*HR verification:
Print Name
Signature
Exception Code: _______________________________________
Date: ____________________________________
Employee Signature:
Date:
FOR AGENCY USE:
Entry Date (P070) “X”
XDNN (plan code)
Date Pre‐note “P”
Date Verified “V”
Initials
ePaystub Enroll:
Date:
Initials:
SFMS
Approval:
Date:
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