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Direct Deposit Forms (Alphabetical)

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Name Number Description
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 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 Payment Trace Number Request (login required) PDF 74-229 Used by agencies to request an ACH trace number for a state direct deposit payment.
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.
PayCard Enrollment Authorization (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.
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.

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