Texas Direct Deposit Form 1 - Free Download
4.2,
4421
votes
Please vote for this template if it helps you.
TEXAS DEPARTMENT OF CRIMINAL JUSTICE
DIRECT DEPOSIT AUTHORIZATION
Section 1 EMPLOYEE INFORMATION
Social Securit
y
Numbe
r
Unit/De
p
t
Name
Work Phone
Section 2 FINANCIAL INSTITUTION FOR ACCOUNT(S)
(completion by representative from financial institution is recommended)
The primary account must be set up at 100%. (If there is a secondary account, this will be 100% of the
remaining net pay after the deposit to the secondary account.) If the primary account is cancelled, and the
employee has a secondary account, the secondary account must be cancelled entirely.
Primary Account (SP1)
New Account Change Financial Institution Change Account Number Change Account Type
*Cancellation of Account *(Financial institution representative name and signature not required.)
Name of Financial Institution
Representative’s Name (please print)
Representative’s Signature
Phone Number
Routing Number
Account Number
Account Type Checking Savings Percent 100%
The secondary account must be set up using a whole dollar amount.
Secondary Account (SP2)
New Account Change Financial Institution Change Account Number Change Account Type
*Cancellation of Account *(Financial institution representative name and signature not required.) Change Amount
Name of Financial Institution
Representative’s Name (please print)
Representative’s Signature
Phone Number
Routing Number
Account Number
Account Type Checking Savings Amount
Section 3 AUTHORIZATION FOR SETUP, CHANGES OR CANCELLATION OF DIRECT DEPOSIT
I authorize the Texas Comptroller of Public Accounts to deposit my payments from the State of Texas to my financial institution electronically.
I understand that the Comptroller of Public Accounts will reverse any payments made to my account in error.
I further understand that the Comptroller’s office will comply at all times with the National Automated Clearing House Association’s rules.
For further information on these rules, please contact your financial institution.
Will these payments be forwarded to a financial institution outside the United States
YES NO
Signature Date
Mail to: TDCJ Payroll Department, PO Box 4015, Huntsville, TX 77342-4015 or FAX to: (936) 437-8644
Revised 02/2010
