SECTION 1: Employee Information
Employee Name: Employee I.D:
SECTION 2: Direct Deposit Information (fill in as necessary)
Instructions: Direct deposits are distributed to accounts in order of the priority starting with priority ‘1’. The total of the percentages cannot exceed 100%.
Designate one (and only one) account to receive any excess funds left over after all direct deposits are processed. Check ‘Partial Allowed?’ to allow the direct deposit amount to
be less than the amount entered in the ‘Amount’ or ‘Percent of Net Pay’ fields.
If you are adding a new account please list this along with all existing accounts in the order of priority.
Percent of Excess? Partial Checking/
Amount Net Pay (check one) Allowed? *Transit # Account # Savings L/A** NEW CHANGE DEL***
1 $
or %
2 $ or %
3 $
or %
4 $ or %
5 $ or %
6 $
or %
7 $ or %
8 $ or %
9 $ or %
10 $ or %
SECTION 3: Sign and Return to Your Payroll Coordinator
I choose to receive my bi-weekly payroll advice through the Commonwealth PayInfo website (available 24 hours). No bi-weekly paper copy will be
issued to me by my employer
Check box if any of the total of any of the above direct deposits go directly to a foreign bank or if the entire amount is forwarded from a domestic bank to a foreign bank
I hereby authorize my employer, through the State Treasurer, to deposit my net pay and/or distributions to the financial institution(s) listed above. My employer, through the
State Treasurer, is also authorized to debit any over deposit or error, which it has caused to be made to my account. The State Treasurer or the employee may cancel this
authorization any time with proper notice to the Personnel/Payroll Office. In the absence of bank documentation, my signature certifies the Transit #(s) and Account #(s)
indication above are correct as shown.
Employee Signature: Date: _ Employee Work Phone:
* NOTE: to find the transit numbers, contact your financial institution for help.
Revised 9/24/09