Direct Deposit Enrollment And Change Form printable pdf download

DIRECT DEPOSIT

ENROLLMENT AND CHANGE FORM

FORM OSCPXA 01

Payroll Unit #

Mid-Month or Bi-Weekly

Monthly Payroll

____________

(to be completed

by Payroll Office)

ENROLL

CHANGE

me in direct deposit

my direct deposit

SOCIAL SECURITY NUMBER:

FIRST NAME:

MI:

LAST NAME:

WORK PHONE

AGENCY OR UNIVERSITY:

WORK E-MAIL ADDRESS:

NUMBER:

NAME OF BANK OR FINANCIAL INSTITUTION:

Deposit to my CHECKING or MONEY MARKET account (my name is on this account)

Deposit to my SAVINGS account (my name is on this account)

I am ATTACHING (check one and STAPLE HERE)

a PHOTOCOPY of a CHECK with my preprinted name and current address

a CHECK marked "VOID" with my preprinted name and current address

an official BANK FORM, certified and stamped by a banking official, which provides my account number and the

bank routing number

a DEPOSIT SLIP for my savings account PLUS the bank routing number shown below:

PLEASE NOTE:

The Office of the State Controller (OSC) will transmit your payment electronically based on the information you have

provided. If the payroll transmission fails because you have given your Payroll Office incorrect or outdated information,

the State can only provide a replacement payment AFTER a refund from the financial institution has been received. It is

important that you provide correct account and bank routing numbers, and that you notify your Payroll Office immediately

if you change banks or account numbers. The OSC has the right to retract and correct payments, as necessary.

This completed form must be received in your Agency Payroll Office no less than 15 days prior to your next pay date

for the direct deposit to be effective for the next pay period.

I acknowledge that electronic payments to the designated account must comply with the provisions of U.S. law, as well as the

requirements of the Office of Foreign Assets Control (OFAC). Check one of the following:

I affirm that, regarding electronic payments the State of North Carolina may remit to the financial institution for

credit to the account that I have designated, the entire payment amount is not subject to being transferred to a

foreign bank account.

I affirm that, regarding electronic payments the State of North Carolina may remit to the financial institution for

credit to the account that I have designated, the entire payment amount is subject to being transferred to a

foreign bank account. I understand that any electronic payments that may be remitted to me may be labeled

with “IAT” as the standard entry class. I acknowledge that availability of funds credited to the account will be

subject to my receiving financial institution’s policies and procedures.

I authorize the Office of the State Controller to initiate direct deposit entries each pay period, and if necessary, adjustments for

any direct deposit entries in error, to the financial institution and account identified on the attached certification document. I

understand and accept the conditions of participation in the direct deposit program. This authority will remain in effect until I

cancel it in writing.

SIGNATURE:

DATE:

Direct Deposit Enrollment And Change Form

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