Direct Deposit Forms (Numerical)
Note: Forms must be downloaded and opened using Adobe Acrobat Reader if you want to fill them out electronically.
Do not fill out forms using your internet browser.
| Form Name | Number | Description |
|---|---|---|
| Direct Deposit Authorization Form (login required) PDF | 74-176 | Used by agencies to provide to payees who wish to receive state payments by direct deposit or change/cancel existing direct deposit information. |
| Direct Deposit Reversal Request (login required) PDF | 74-191 | Used by agencies to request an erroneous direct deposit payment be reversed through the Automated Clearing House (ACH) system. |
| Tax Refund Direct Deposit Authorization (login required) PDF | 74-221 | Used by the Comptroller’s Revenue Accounting Division to provide to taxpayers who wish to receive tax refund payments by direct deposit. |
| Pay Card Enrollment Authorization – Employees (login required)PDF | 74-224 | This form is used by employees to sign up to receive payroll payments through the Employee PayCard program. |
| Reclamation Request for ACH Transactions (login required) PDF | 74-226 | Used by a agencies upon notification of a payee’s death to reclaim a pension, annuity or benefit payment made by direct deposit for which the payee or its estate was not entitled. |
| ACH (Direct Deposit) Payment Destination Confirmation (login required) PDF | 74-227 | Used by agencies who must require payees to confirm whether their state payments are destined to be forwarded outside of the U.S. |
| Direct Deposit Payment Trace Number Request (login required) PDF | 74-229 | Used by agencies to request an ACH trace number for a state direct deposit payment. |