California Direct Deposit Form 2 - Free Download
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I HEREBY CERTIFY THAT I AM THE DULY APPOINTED,
QUALIFIED AND ACTING OFFICER OF THE HEREIN NAMED
AGENCY/CAMPUS AND THAT, BEING SO AUTHORIZED, DO
CERTIFY THAT THIS EMPLOYEE IS ELIGIBLE FOR DIRECT
DEPOSIT.
FOR SCO ONLY
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I hereby cancel my Direct Deposit authorization.
2. ROUTING NUMBER
4. FINANCIAL INSTITUTION NAME
DATE RECEIVED
IN EMPLOYING
OFFICE
1. EFFECTIVE
DATE
Last)
ZIP)
1. TYPE OF ENROLLMENT ACTION
1.
2.
3.
1. TYPE OF ACCOUNT- MUST BE CHECKED. IF LEFT BLANK, WILL BE PROCESSED AS CHECKING
5.
STD. 699 (REV. 12/2011)
COMPLETION INSTRUCTIONS AND PRIVACY NOTICE ARE ON
THE REVERSE OF THE EMPLOYEE COPY. PLEASE TYPE OR
USE BALL POINT PEN–PRINT CLEARLY.
SECTION A (To be completed by employee)
NEW
CHANGE
CANCEL
2. SOCIAL SECURITY NUMBER
3. NAME (First Middle
SECTION B (To be completed by employee if NEW or CHANGE box in Section A is checked)
C (Checking) S (Savings)
Verify Routing/Depositor Numbers with Financial Institution
3. DEPOSITOR ACCOUNT NUMBER
FINANCIAL
INSTITUTION
ADDRESS
(Number and Street
City / State
SECTION C (To be completed by employee if NEW or CHANGE box in Section A is checked)
I hereby authorize the State Controller’s Office to provide for direct deposit of any salary or wages due me, less any mandatory or
authorized withholding or deductions therefrom, in the above designated account.
If at any time the amount of salary or wages so deposited exceeds the amount of salary or wages actually due and payable to me,
I hereby authorize the State Controller’s Office to either:
If the State is legally obligated to withhold any part of my wage or salary payment for any reason, or if I no longer meet eligibility
requirements for the Direct Deposit program, I understand the State Controller’s Office may terminate my enrollment in the program.
If any action taken by me results in nonacceptance of a direct deposit by the designated financial institution, I understand that the
State assumes no responsibility for processing a supplemental salary or wage payment until the amount of the nonacceptance
deposit is returned to the State by the financial institution.
SIGNATURE
DATE
SECTION D (To be completed by employee if CANCEL box in Section A is checked)
1. AGENCY/CAMPUS NAME
2. AGENCY CODE 3. UNIT
TELEPHONE NUMBER
CHECK IF
CALNET
MO. DAY YR.
DISTRIBUTION:
CANARY–TO AGENCY
PINK–TO EMPLOYEE
This authorization remains in full force and effect until
the State Controller’s Office receives written notification
from the employee of its termination, or until the State
Controller’s Office or appointing authority deems it
necessary to terminate the agreement.
4. REMARKS
5. AUTHORIZED AGENCY/CAMPUS SIGNATURE
MO. DAY YR.
SECTIONS A, B, AND C MUST
BE COMPLETED
SECTIONS A, B, AND C MUST
BE COMPLETED
SECTIONS A AND D MUST BE
COMPLETED
SECTION E (To be completed by state agency or campus personnel/payroll office only)
SIGNATURE
DATE
STATE OF CALIFORNIA í CONTROLLER'S OFFICE
WHITE–TO STATE CONTROLLER'S OFFICE
(b) Recover such overpayment from the above-designated account.
(a) Withhold a sum equal to the overpayment from future salary or wages; or
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CHECK BOX IF SEMI-MONTHLY EMPLOYEE
100% of the net deposit will not be sent to a financial
institution outside the jurisdiction of the United States.
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