ESBD_397687_1740091501778_ATTACHMENT G.1 Direct Deposit Authorization Form 74-176.pdf

For Comptroller’s Use Only

1. Select transaction types:

New setup (Sections 2, 3, 5 and 6) Change account type (Sections 2, 3, 4, 5 and 6)

(Sections 2, 3, 4, 5 and 6) Cancellation (Sections 2 and 6 - Sections 7 and 8 for state agency use)

Change account number (Sections 2, 3, 4, 5 and 6) Change custodial agency

26. Reason 27. Date

................................................... YES NO

If "YES

23. Authorized signature 24. Printed name 25. Date

28. Authorized signature 29. Date

30. Phone (Area code and number) 31. Agency number

32. Agency name

33. Comments

34. Please return to the paying agency at the following address:

( ) ext.

8. Financial institution name 9. City 10. State

11. Routing number (9 digits) 12. Customer account number (maximum 17 characters) 13. Account type

Checking Savings

14. Financial representative name (optional) 15. Title (optional)

16. Financial representative signature (optional) 17. Phone (Area code and number) (optional) 18. Date (optional)

( ) ext.

5. Payee name 6. Phone (Area code and number)

7. Mailing address (Street, city, state and ZIP code)

Social Security number (SSN)* State employee

Vendor or other recipient

4. Mail code (If not known, ext.( )

19. Routing number (9 digits) 20. Customer account number (maximum 17 characters) 21. Account type

Checking Savings

74-176 (Rev.9-21/21)

STATE OF TEXAS

Direct Deposit Authorization This form may be used by vendors, individual recipients or state employees to receive payments

Transaction Types

S E

C T

IO

N

S

E C

T

IO

N

New Account Information (Setups and Changes)

S E

C T

IO

N

Existing Account Information (Changes Only)

S E

C

(required)

S E

C

Authorization for Setup, Changes or Cancellation (required)

S E

C T

IO

N

I authorize the state agency that issues my state of Texas payments via the Texas Comptroller of Public Accounts to electronically deposit my pay-of Texas payments via the Texas Comptroller of Public Accounts.

I further understand that the agency that issues my state of Texas payments and the Texas Comptroller of Public Accounts will comply at all times with the National Automated Clearing House Association's rules.

Cancellation by Agency (for state agency use)

S E

C

State Agency Contact (for state agency use)

S E

C T

IO

N

Form 74-176 (Back)(Rev.9-21/21)

Instructions for Direct Deposit Authorization You have certain rights under Chapters 552 and 559, Government Code, to review, request and correct information we have on

Section 1: Transaction Type(s)

1. Select the appropriate transaction type(s) and complete the corresponding sections.

Note:

(Required)

2. Payee type: Indicate whether the payee is a state employee or a vendor/recipient.

Note:

3. Identification number: Indicate the type of identification number and provide the associated 9- or 11-digit number.

4. Mail code: Enter the 3-digit mail code.

5. Payee name: Enter the payee’s name.

6. Phone: Enter the payee’s area code, phone number (and extension, if applicable).

7. Mailing address: Enter the payee’s mailing address, city, state and ZIP code.

Section 3: New Account Information (Setups and changes)

8. Financial institution name: Enter the name of the payee’s financial institution.

9. City: Enter the city of the payee’s financial institution.

10. State: Enter the 2-character abbreviation for state of the payee’s financial institution.

11. Routing number: Enter the 9-digit routing number of the payee’s financial institution.

12. Customer account number: Enter the payee’s account number (maximum 17 characters).

13. Type of account: Indicate whether the payee’s account type is a checking account or a savings account.

14. Financial representative name: (optional) Enter the name of the financial representative.

15. Title: (optional) Enter the title of the financial institution representative.

16. Financial representative signature: (optional) Original signature of the financial representative.

17. Phone: (optional) Enter the area code, phone number (and extension, if applicable) of the financial representative.

18. Date: (optional) Enter the date the financial representative signed the form.

Section 4: Existing Account Information (Changes only)

19. Routing number: Enter the 9-digit routing number currently on file with the Comptroller’s office.

20. Customer account number: Enter the payee’s account number currently on file with the Comptroller’s office.

21. Account type: Select the payee’s account type currently on file with the Comptroller’s office.

(Required)

22. Payment Destination: Select YES or NO Note: If YES

Section 6: Authorization for Setup, Changes or Cancellation (Required)

23. Authorized signature: Original signature of the payee is required.

24. Printed name: Enter or print the name of the payee or vendor/recipient signing the form.

25. Date: Enter or print the date the form was signed.

Section 7: Cancellation by Agency (for state agency use)

26. Reason: Enter the reason for cancellation of the payee’s direct deposit information.

27. Date: Enter the date the cancellation was determined.

Section 8: State Agency Contact (for state agency use)

28. Authorized signature: Original signature of the agency’s authorized representative is required.

29. Date: Enter the date the agency’s representative signed the form.

30. Phone: Enter the area code, phone number and extension (if applicable) of the agency’s representative.

31. Agency number: Enter the 3-digit agency number.

32. Agency name: Enter the agency’s name.

33. Comments: (optional) Enter comments, if needed.

34. Return to Paying State Agency: This area autopopulates with the name and address of the paying state agency to which this form will be returned.

Questions?

State Employees: Contact your agency’s Human Resource department or payroll staff.

Vendors/Recipients: Contact the paying agency’s accounts payable staff.

State Agencies: Contact Fiscal Management, Payment Services at 512-936-8138.

*Federal Privacy Act Statement: