DIRECT DEPOSIT FORM FOR NYS EMPLOYEES
RETURN COMPLETED FORM TO YOUR AGENCY/DEPARTMENT PAYROLL OR PERSONNEL OFFICE AC 2772 (REV 04/2020)
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
my NYS salary payment to be sent to the designated financial institution(s) to be deposited into the specified account(s), and
-payroll amounts due to me to be sent to the designated financial institution to be deposited into the balance account designated.
at this form supersedes any previous elections I have made, and that changes may take up to two payroll periods to
EMPLOYEE SIGNATURE ________________________________________________________
DATE ____________________
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, em
ployees
may experience a delay in payments. The financial institution may cancel the agreement by providing the employee and t
he State
agency with a written notice 30 days in advance of the cancellation date. The financial institution cannot cancel the authori
zation without
notification to both the employee and the State agency. The State agency may cancel an employee’s direct de
posits 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 wil
l be provided to the
designated financial institution(s) and/or their agent(s) for the purpose of processing payments, and for other official busi
ness of the
Office of the State Comptroller. No further disclosure of this information will be made unless suc
h 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 D
irect
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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