Fillable DIRECT DEPOSIT FORM FOR NYS EMPLOYEES (City University of New York)

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DIRECT DEPOSIT FORM FOR NYS EMPLOYEES (City University of New York)

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BROWSE CITY UNIVERSITY OF NEW YORK FORMS

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DIRECT DEPOSIT FORM FOR NYS EMPLOYEES
RETURN COMPLETED FORM TO YOUR AGENCY/DEPARTMENT PAYROLL OR PERSONNEL OFFICE AC 2772 (REV 01/2021)
Page 1 of 2
SECTION A: EMPLOYEE INFORMATION (REQUIRED)
NAME (LAST, FIRST, MI)
NYS EMPLID
N
LAST 4 SSN
PHONE (AREA CODE + PHONE NUMBER)
WORK EMAIL
HOME ADDRESS (STREET, CITY, STATE, ZIP CODE)
SECTION C: ADDITIONAL ACCOUNT INFORMATION (OPTIONAL)
Up to seven
fixed amount or percentage deposits may be processed in addition to the balance account listed in Section B. The
employee’s name
must appear on the account(s). A voided check or written verification from the financial institution showing the account
number, routing number, and name(s) on the account must accompany this form for each account listed.
DEPOSIT ORDER-1
ACTION Add
Change Distribution Add/Change Joint Account Holder Cancel
TYPE
Checking
Savings
ACCOUNT # ROUTING #
FINANCIAL INSTITUTION
DISTRIBUTION $________
________ %
DEPOSIT ORDER-2
ACTION Add
Change Distribution Add/Change Joint Account Holder Cancel
TYPE
Checking
Savings
ACCOUNT # ROUTING #
FINANCIAL INSTITUTION
DISTRIBUTION $________
________%
DEPOSIT ORDER-3
ACTION Add
Change Distribution Add/Change Joint Account Holder Cancel
TYPE
Checking
Savings
ACCOUNT # ROUTING #
FINANCIAL INSTITUTION
DISTRIBUTION
$________
________%
DEPOSIT ORDER-4
ACTION Add
Change Distribution Add/Change Joint Account Holder Cancel
TYPE Checking
Savings
ACCOUNT #: ROUTING #
FINANCIAL INSTITUTION
DISTRIBUTION $________
or ________%
DEPOSIT ORDER-5
ACTION Add
Change Distribution Add/Change Joint Account Holder Cancel
TYPE
Checking
Savings
ACCOUNT # ROUTING #
FINANCIAL INSTITUTION
DISTRIBUTION $________
or ________%
DEPOSIT ORDER-6
ACTION Add
Change Distribution Add/Change Joint Account Holder Cancel
TYPE
Checking
Savings
ACCOUNT # ROUTING #
FINANCIAL INSTITUTION
DISTRIBUTION $________
or ________%
DEPOSIT ORDER-7
ACTION Add
Change Distribution Add/Change Joint Account Holder Cancel
TYPE Checking
Savings
ACCOUNT # ROUTING #
FINANCIAL INSTITUTION
DISTRIBUTION $________
or ________%
SECTION B: BALANCE ACCOUNT INFORMATION (REQUIRED)
Participating in full Direct Deposit requires one balance account; this account will receive any excess of funds after all other distributions
are deposited as indicated. The
balance account designated will be last in the deposit order. Non-payroll amounts, such as travel
reimbursements, will be deposited in
the balance account. If no other accounts are listed, the full net pay will be deposited into the
balance account.
The employee’s name must appear on the account. A voided check or written verification from the financial institution
showing the acc
ount number, routing number, and name(s) on the account must accompany this form for the balance account.
BALANCE ACCOUNT (REQUIRED)
ACTION New Change Account Add/Change Joint Account Holder
TYPE Checking Savings ACCOUNT # ROUTING #
FINANCIAL INSTITUTION
DISTRIBUTION Excess
( )
or
or
or
DIRECT DEPOSIT FORM FOR NYS EMPLOYEES
RETURN COMPLETED FORM TO YOUR AGENCY/DEPARTMENT PAYROLL OR PERSONNEL OFFICE AC 2772 (REV 01/2021)
Page 2 of 2
SECTION D: DIRECT DEPOSIT STATEMENT OPTIONS (OPTIONAL)
Check the box to opt out of receiving a printed copy of your direct deposit pay stub:
*Go Paperless
is only provided to agencies enrolled in NYSPO. Contact your payroll officer or Human Resources office to determine
whether your agency is enrolled in NYSPO.
SECTION E: AUTHORIZATION (REQUIRED)
The joint account holder for accounts listed in Sections B and C, if any, must sign on the corresponding line for new/additional accounts
or changes in account holder(s). By signing this form, the employee and any joint account holder allows the State, through th
e financial
institution, to debit the account in order to recover
any salary to which the employee was not entitled or that was deposited to the account
in error. This means of recovery shall not prevent the State from utilizing any other lawful means to retrieve salary payments to which
the employee is not e
ntitled.
BALANCE ACCOUNT JOINT ACCOUNT HOLDER DATE
DEPOSIT ORDER-1 JOINT ACCOUNT HOLDER DATE
DEPOSIT ORDER-2 JOINT ACCOUNT HOLDER DATE
DEPOSIT ORDER-3 JOINT ACCOUNT HOLDER DATE
DEPOSIT ORDER-4 JOINT ACCOUNT HOLDER DATE
DEPOSIT ORDER-5 JOINT ACCOUNT HOLDER DATE
DEPOSIT ORDER-6 JOINT ACCOUNT HOLDER DATE
DEPOSIT ORDER-7 JOINT ACCOUNT HOLDER DATE
I certify that I read and understand the instructions to this form, including the authorization for recovery. In signing this form,
I authorize all of my NYS salary payments to be sent to the designated financial institution(s) to be deposited into the
specified account(s), and all non-payroll amounts due to me to be sent to the designated financial institution to be deposited into the
balance account designated. I understand that this form supersedes any previous elections I have made, and that changes may
take up to two payroll periods to become effective.
EMPLOYEE SIGNATURE ________________________________________________________ DATE ____________________
CANCELLATIONS
The agreement represented by this authorization will remain in effect until canceled by the employee, the financial institution, or the
State agency. Employees should maintain accounts canceled and replaced by new accounts until the new transaction is complete. If
canceled accounts are not temporarily maintained until the new account receives the employee’s direct deposit transaction, employees
may experience a delay in payments. The financial institution may cancel the agreement by providing the employee and the State
agency with a written notice 30 days in advance of the cancellation date. The financial institution cannot cancel the authorization without
notification to both the employee and the State agency. The State agency may cancel an employee’s direct deposits when internal
control policies would be compromised by this form of salary payment.
NEW YORK STATE PERSONAL PRIVACY LAW NOTIFICATION
The New York State Office of the State Comptroller Bureau of State Payroll Services requests personal information on this form to
operate the New York State Direct Deposit/Electronic Funds Transfer Program. This information is being requested pursuant to State
Finance Law §200(4) and Part 102 of Title 2 of the New York Codes, Rules and Regulations. The information will be provided to the
designated financial institution(s) and/or their agent(s) for the purpose of processing payments, and for other official business of the
Office of the State Comptroller. No further disclosure of this information will be made unless such disclosure is authorized or required
by law. An employee’s failure to provide the requested information may delay or prevent the receipt of payments through the Direct
Deposit/Electronic Funds Transfer Program. The information provided will be maintained in the State Payroll System under the direction
of the Bureau of State Payroll Services.
Go Paperless* - I do not want a printed copy of my Direct Deposit pay stub sent to me. I understand that I will not receive a
printed copy of my Direct Deposit pay stub. I understand that I can view and print my electronic pay stubs as well as
change my Direct Deposit statement option with NYS Payroll Online (NYSPO): https://psonline.osc.ny.gov
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Completed 2 February 2022

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