THE CITY OF NEW YORK
PAYROLL MANAGEMENT SYSTEM
Direct Deposit of Net Pay
Enrollment / Cancellation
TYPE OF
ACTION
NEW
ENROLLMENT
CHANGE OF
ACCOUNT TYPE
CHANGE OF NAME
ON ACCOUNT
CHANGE OF
ACCOUNT NUMBER
CANCELLATION
Attach a voided check or most recent savings statement. Check all that apply.
EMPLOYEE SECTION
EMPLOYEE
IDENTIFICATION
WORK TELEPHONE
FIRST
M.I.
LAST
SOCIAL SECURITY NUMBER
CHANGE OF
ABA NUMBER
ENROLLMENT
PERSON(S) NAMED ON ACCOUNT (PRINT EXACTLY - INCLUDE TRUSTEE OR JOINT OWNER)
PERSON 1
PERSON 2
ABA NUMBER* ACCOUNT NUMBER**
ACCOUNT TYPE
SAVINGS CHECKING
(CHECK ONLY ONE)
EMPLOYEE AUTHORIZATION
I hereby authorize The City of New York to deposit my net pay directly into my checking or savings account as requested. I also
grant authorization for the reversal of a credit to my account in the event the credit was made in error. I understand that, under
the "National Automated Clearing House Association" operating guidelines and rules, The City of New York can only reverse
the amount of the incorrect direct deposit. I agree that this authorization will remain in effect until I provide to my agency a written
cancellation to terminate the service.
EMPLOYEE
SIGNATURE
CANCELLATION
I hereby authorize The City of New York to cancel my direct deposit agreement.
EMPLOYEE
SIGNATURE
AGENCY PAYROLL SECTION
CHECK DIGIT
DOCUMENT # JSN PAYROLL #
ENROLLMENT
REJECTION REASONS
INACTIVE
LEAVE STATUS
PAYCYCLE
IS "A"
OTHER
ENTERED
INTO PMS
MANAGER/
SUPERVISOR
Signature
Name
(Please Print)
Signature
Name
(Please Print)
*ABA BANK NUMBER:
CHECKING ACCOUNTS --
The ABA number is the first nine (9) numbers prior to the account number at the bottom left corner of the check.
SAVINGS ACCOUNTS --
Contact your bank for ABA number, if not known.
(**See check, passbook or account statement for account number)
MONTH DAY YEAR
MONTH DAY YEAR
MONTH DAY YEAR
MONTH DAY YEAR
SUBMIT COMPLETED FORM TO:
YOUR AGENCY DIRECT DEPOSIT COORDINATOR OR
YOUR PAYROLL OFFICE
www.NYC.gov/payroll
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