Florida Direct Deposit Form 3 - Free Download
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STATE OF FLORIDA
DIRECT DEPOSIT AUTHORIZATION
Alex Sink, Chief Financial Officer
PLEASE TYPE OR PRINT CLEARLY
Your Social Security Number
–
–
Last Name, First Name M.I.
Your Home Mailing Address (Number, Street)
City
State Zip Code
Work Telephone
(____)
Other Telephone (home, cell, etc.)
(____)
Direct Deposit (1) Start...............................
Action Requested (2) Change..........................
(Check Only One) (3) Name Change Only.......
(4) Stop...............................
For State of Florida Employees only.
Account Type (1) Checking .......................
(Check Only One) (2) Savings .........................
Your Account Number – Start at left, leave unused spaces blank
Transit Routing Number of Your Financial Institution
Name of Your Financial Institution
Telephone number of Your Financial Institution
(____)
Employee or Legal Representative Signature Date
THIS FORM MUST BE SIGNED AND DATED BY PAYEE
Signature above signifies acceptance of the terms and conditions in
AGREEMENT to the right.
State employees may view salary payments and
expense reimbursements at https://flair.dbf.state.fl.us
PLEASE READ AND CAREFULLY FOLLOW INSTRUCTIONS!
For a
Start or Change all boxes must be completed;
do not leave information blank!
This form will start, change, or stop direct deposit for all
payments received by you from the State of Florida. You may
not have direct deposit to more than one account at one time.
Name: Please be sure your last name on this form matches the last
name on your W-4 on file with your personnel office. Your direct
deposit will not start if the last names do not match. If you change
your last name on your W-4, you also must change your last name for
direct deposit. You may fax a copy of signed, revised W-4 to the
number below to make the change.
Direct Deposit Action Requested:
1. Check Start if you don’t have direct deposit and wish to.
2. Check Change if you have direct deposit and wish to change
your financial institution or just your account number or account
type (Checking or Savings). Your current direct deposit is
stopped when a change request is received. While the change is
being processed, you will be paid by warrant (check).
3. Check
Name Change Only if you are changing only your
name to correspond to your W-4. Complete the top portion of
the form and sign and date it.
4. Check
Stop if you wish to stop your direct deposit. Stops are
processed the day they are received.
Account Number: Please make sure the account number written
on this form is correct.
Transit Routing Number: This is the nine-digit number that
identifies your financial institution (Bank, Savings and Loan or
Credit Union). It is found in the bottom left-hand corner of your
personal check.
If you’re not sure about your Account information , PLEASE
CONTACT YOUR FINANCIAL INSTITUTION.
AGREEMENT
I hereby authorize and request the State of Florida to initiate
credit entries and, if necessary, a debit entry in accordance with
NACHA rules reversing a credit entry made in error, to my
account at the financial institution named. This direct deposit is to
remain in effect until withdrawn by: (a) me in writing with
sufficient notice to the State to allow adequate time to effect
termination; (b) my death or legal incapacity; (c) the financial
institution or (d) the State of Florida. It will purge approximately
six (6) months after my last wage.
Special Note: Please make sure your direct deposit has
stopped
before closing your account. Otherwise, the funds will be returned to
the state and cause a seven to ten day delay before you receive your
payment in the mail.
Forms with deposit slips attached will be
rejected; the banking codes are not correct.
Tape a voided personal check here for verification.
If a savings account, please verify account
information with your financial institution.
FAX to:
(850) 413-5549
If you fax your form, retain
the original, do not mail it.
Or mail to:
Direct Deposit Section
Department of Financial Services
200 East Gaines Street
Tallahassee, FL 32399-0359
Telephone (850) 413-5517
Please allow 4 to 6 weeks for your direct deposit to begin.
DFS-A1-26S, Rev. Jan. 2007
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