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Payroll System (Check one) Regular Contract University of Maryland
Social Security Number Employee’s Name (please print)
- -
Agency Code Agency Name (please print)
I authorize the State of Maryland Central Payroll Bureau to take the following action with my net salary:
(Check One)
1. Initiate Deposit directly to my checking/savings account
(Will take at least two pay periods to allow for pre-note process.)
2. Change account type(checking/savings account), and/or bank routing number to which my net salary
is deposited (cancel of old account will occur within 21 days for receipt of CPB; you will receive
a payroll check until the new account is established)
Do not close account until payroll check is issued.
3. Discontinue direct deposit into my checking/savings and issue a payroll check instead.
Do not close account until payroll check is issued.
Bank Name:
(Omit if action 3 is checked)
Processed by:
Account Type: (Must Check One)
If not marked this form will be returned
Checking Savings
CPB Use Only
Effective PPE:
Bank Number
Verify carefully. For checking copy directly from your personal check. Do not
include your check number. Do not use your deposit slip number.
Checking/Savings Account Number
IAT requirement Check box if your full net pay is subsequently transferred to a foreign bank.
I authorize the State of Maryland to deposit my net salary to the bank and account named above. This authorization is to remain in force until the State of
Maryland receives written notification from me of its termination in time and manner that allows the State and the bank a reasonable opportunity to act upon it.
In the event that the State of Maryland notifies the bank that funds to which I am not entitled have been deposited to my account in error, I authorize and direct
the bank to return said funds to the State as soon as possible. If the funds erroneously deposited to my account have been drawn from that account so that
return of those funds by the bank to the State is not possible, I authorize the State to recover those funds by setting off the amount erroneously paid me from
any future payments from the State until the amount of the erroneous deposit has been recovered, in full.
_________________________ __________________________________ _________________________
Date Employee signature Daytime phone number
Instructions:
• Only one account is permitted for direct deposit. You can choose either checking or savings not both.
• Type or print only (except signature).
• Use black ink only.
• Complete all blocked areas in the top part of form except for the section “CPB use only.”
• Read authorization and sign the completed form. Unsigned or Incomplete forms will be returned.
• Deposit amount will be full net amount of pay into either your checking/savings account..
• If changing your account type, bank and or account number, you will receive a payroll check until new direct deposit becomes effective.
• Do not send a voided blank check.
• Send completed form to Central Payroll Bureau, P.O. Box 2396, Annapolis, MD 21404. Phone 410-260-7401.
S
S
T
T
A
A
T
T
E
E
O
O
F
F
M
M
A
A
R
R
Y
Y
L
L
A
A
N
N
D
D
P
P
A
A
Y
Y
R
R
O
O
L
L
L
L
D
D
I
I
R
R
E
E
C
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D
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H
H
O
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I
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Z
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A
A
T
T
I
I
O
O
N
N
Payroll System (Check one) Regular Contract University of Maryland
Social Security Number Employee’s Name (please print)
- -
Agency Code Agency Name (please print)
I authorize the State of Maryland Central Payroll Bureau to take the following action with my net salary:
(Check One)
1. Initiate Deposit directly to my checking/savings account
(Will take at least two pay periods to allow for pre-note process.)
2. Change account type(checking/savings account), and/or bank routing number to which my net salary
is deposited (cancel of old account will occur within 21 days for receipt of CPB; you will receive
a payroll check until the new account is established)
Do not close account until payroll check is issued.
3. Discontinue direct deposit into my checking/savings and issue a payroll check instead.
Do not close account until payroll check is issued.
Bank Name:
(Omit if action 3 is checked)
Processed by:
Account Type: (Must Check One)
If not marked this form will be returned
Checking Savings
CPB Use Only
Effective PPE:
Bank Number
Verify carefully. For checking copy directly from your personal check. Do not
include your check number. Do not use your deposit slip number.
Checking/Savings Account Number
IAT requirement Check box if your full net pay is subsequently transferred to a foreign bank.
I authorize the State of Maryland to deposit my net salary to the bank and account named above. This authorization is to remain in force until the State of
Maryland receives written notification from me of its termination in time and manner that allows the State and the bank a reasonable opportunity to act upon it.
In the event that the State of Maryland notifies the bank that funds to which I am not entitled have been deposited to my account in error, I authorize and direct
the bank to return said funds to the State as soon as possible. If the funds erroneously deposited to my account have been drawn from that account so that
return of those funds by the bank to the State is not possible, I authorize the State to recover those funds by setting off the amount erroneously paid me from
any future payments from the State until the amount of the erroneous deposit has been recovered, in full.
_________________________ __________________________________ _________________________
Date Employee signature Daytime phone number
Instructions:
• Only one account is permitted for direct deposit. You can choose either checking or savings not both.
• Type or print only (except signature).
• Use black ink only.
• Complete all blocked areas in the top part of form except for the section “CPB use only.”
• Read authorization and sign the completed form. Unsigned or Incomplete forms will be returned.
• Deposit amount will be full net amount of pay into either your checking/savings account..
• If changing your account type, bank and or account number, you will receive a payroll check until new direct deposit becomes effective.
• Do not send a voided blank check.
• Send completed form to Central Payroll Bureau, P.O. Box 2396, Annapolis, MD 21404. Phone 410-260-7401.
CPB/c/dd/0059/2-2010
