ESBD_469621_1763138465839_SOL_EXH_F.5_Direct Deposit Authorization Form.pdf

This is a Direct Deposit Authorization form (Form 74-176) issued by the State of Texas for use by vendors, individual recipients, and state employees to establish, modify, or cancel direct deposit arrangements for payments from the state. The form accommodates multiple transaction types including new account setup, changes to financial institution or account information, account type modifications, and cancellation of direct deposit services. The form requires completion of payee identification information (Section 2), which includes designation of payee type as either a state employee or vendor/recipient, along with appropriate identification numbers such as Texas Identification Number (TIN), Employer Identification Number (EIN), Social Security Number (SSN), or Individual Taxpayer Identification Number (ITIN). New account information (Section 3) should ideally be completed by the financial institution and includes routing number, customer account number, account type designation, and optional financial representative details.

Additional required sections include International Payments Verification (Section 5), which determines whether payments will be forwarded to financial institutions outside the United States, and Authorization for Setup, Changes or Cancellation (Section 6), which requires the payee's original signature. State agencies utilizing this form must complete Section 8 (State Agency Contact) with authorized signature, date, agency number, and agency name before returning the completed form to the designated paying agency. The form includes provisions for agency-initiated cancellations with documented reasons and dates. Inquiries regarding the form should be directed to the relevant department: Human Resources or payroll staff for state employees, accounts payable staff for vendors and recipients, or Fiscal Management, Payment Services for state agencies.