New York Direct Deposit Form 1 - Free Download
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New York Direct Deposit Form 1
New York Direct Deposit Form 1
AC 2772 (Rev. 11/12) PLEASE SEE REVERSE SIDE FOR INSTRUCTIONS
Direct Deposit Form for NYS Employees
(To be used for enrollment, changes and cancellations)
Section A: Employee Information
NAME (LAST, FIRST, MI) ________________________________________________ WORK PHONE # ( ) ____________
NYS EMPLID # __ __ __ __ __ __ __ __ __ AGENCY/DEPT CODE __ __ __ __ __
For more than three accounts or if you prefer to list each Financial Institution on a separate form, use additional forms as necessary. Up to seven fixed
amount or percentage deposits may be processed as well as one excess (net pay) deposit.
Section B:
Account Type
New or
Additional *
()
Change
Joint
Account
Holder *
()
Change
Amount or
Percentage
()
Cancel
()
Name of
Financial Institution
Account Number Amount,
Percentage or
Excess
1. Savings Checking
2. Savings Checking
3. Savings Checking
*For new/additional accounts with joint account holders or to add a joint account holder to existing accounts, both signatures are required in Section D.
Section C: This section must be completed by your financial institution for new/additional accounts when directing
funds into a savings account or into a checking account if a voided personal check is not attached. The employee’s
name MUST appear on the account(s).
As a representative of the below named financial institution, I certify that this institution is ACH capable and agree to receive and deposit the salary to
the account shown above in accordance with Part 102 of the Codes, Rules, and Regulations of the State of New York and to be bound by such rules.
Salary credited to the account below will be available to the depositor on payday.
1. NAME OF FINANCIAL INSTITUTION __________________________________________ Account Type Savings Checking
Depositor’s Account Number (EFT Format) Routing Number
________________________________________________________ __ __ __ __ __ __ __ __ __
Print or Type Representative’s Name
Signature of Representative
Telephone Number
Date
2. NAME OF FINANCIAL INSTITUTION __________________________________________ Account Type Savings Checking
Depositor’s Account Number (EFT Format) Routing Number
________________________________________________________ __ __ __ __ __ __ __ __ __
Print or Type Representative’s Name
Signature of Representative
Telephone Number
Date
3. NAME OF FINANCIAL INSTITUTION __________________________________________ Account Type Savings Checking
Depositor’s Account Number (EFT Format) Routing Number
________________________________________________________ __ __ __ __ __ __ __ __ __
Print or Type Representative’s Name
Signature of Representative
Telephone Number
Date
Section D: Employee/Joint Account Holders Certification: I certify that I read and understand the instructions to
this form, including the authorization for recovery. In signing this form, I authorize my salary payment to be sent to the designated
financial institution(s) to be deposited into the specified account(s). The joint account holder for accounts listed in Section B, if any, must sign
on the corresponding line for new/additional accounts or account holder(s).
Employee Signature___________________________________________________________________________ Date __________________
B-1 Joint Account Holder ___________________________________________________________________________ Date ____________________
B-2 Joint Account Holder ___________________________________________________________________________ Date ____________________
B-3 Joint Account Holder ___________________________________________________________________________ Date ____________________
This form is a legal document and cannot be altered by the agency, employee or financial institution.
If there are any changes, the employee must complete a new form.
N
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