Fillable State of Hawaii - Form 59 HIP Direct Deposit Form

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State of Hawaii - Form 59 HIP Direct Deposit Form

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The State of Hawaii - Form 59 HIP Direct Deposit Form form is 2 pages long and contains:

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STATE ACCOUNTING FORM D-59
JANUARY 1, 2018
STATE OF HAWAII
DIRECT DEPOSIT FORM
Note: If you have access to the Hawaii Information portal, you may enroll or change your direct deposit
online. Please check with your Department to see if you have access to these online services.
SECTION A
Department
Division or School
Last Name, First Name, Middle Initial
Day-Time Phone Number
Employee ID Number (if known)
SSN
The undersigned
requests to:
☐
ADD NEW ACCOUNT or
☐
CANCEL ACCOUNT or
☐
EDIT ACCOUNT
SECTION B – Please provide your account information in the area below. It is highly recommended that you
verify your account information with your financial institution.
SECTION C – Deposit Authorization and Agreement
By signing this form:
• I authorize the State of Hawaii to add, cancel or edit the account indicated above for the purpose of
direct depositing my employment compensation.
• I agree not to hold the State of Hawaii responsible for any delay or loss of funds due to incorrect or
incomplete information I supplied above, or due to an error on the part of the financial institution in
depositing funds to my account.
___________________________________________ _____________________
EMPLOYEE SIGNATURE DATE
___________________________________________ ______________________
ENTERED BY DATE
Name of Financial Institution:
9 Digit Routing
Number (ACH):
Account Number:
Account Type:
□
Checking
□
Savings Deposit Type:
□
Balance
□
Amount
□
Percent
Deposit Order: _______________ Amount or Percent (if applicable): _______________
Submit this form to your Department Payroll Office for processing
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signature
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dd mmm yyyy
dd mmm yyyy
STATE ACCOUNTING FORM D-59
JANUARY 1, 2018
DIRECT DEPOSIT FORM, SAFORM D-59
Instructions
As an alternative to receiving a payroll check, you can have your net wages deposited directly into
your bank or credit union account. Please complete this form to activate direct deposit.
All sections of the Direct Deposit Form, State Accounting Form D-59, must be completed for the form
to be valid. Alterations to this form are not allowed. New forms must be submitted to: 1) add an
account; 2) cancel an existing account; or 3) make changes to an existing account. Updates can also
be submitted directly through the Hawaii Information portal.
Section A – Personal Information
Department: name of the department you are employed (e.g., Dept of Transportation)
Division or School: name of the division (e.g., Harbors Division) or school you work at
Last Name, First Name, Middle Initial: enter your full name as shown on your personnel records
Day-Time Phone Number: best contact phone number to reach you
Employee ID Number
: enter your employee ID number, if known
SSN: enter your Social Security Number
Section B – Account Information
Please refer to your financial institution to provide your account information and routing number to
help you complete this section.
See the bottom of your check for the Routing Number and Account Number
( 9 digit Routing Number ) (Account Number: length may vary)
Account Type: Indicate if this is a Checking or Savings account
Deposit Type: indicate if the entire Balance, a certain Amount or Percent is to be deposited into this
account. If
Amount
or
Percent
is checked, indicate the amount or percent of net wages
Deposit Order: enter the order of the deposit (e.g., 1, 2, 3, etc.). If the Deposit Type is Balance,
enter 999 as the Deposit Order
Section C – Deposit Authorization and Agreement
Please address all questions to your Department Human Resources Office, or refer to the following
website:
Read the Agreement, sign and date, and submit the completed form to your designated Department
Payroll Office for processing.
http://www.ags.hawaii.gov/hawaiipay
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State of Hawaii - Form 59 HIP Direct Deposit Form

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Completed 24 May 2020

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