ESBD_565344_1791381735860_ATTACHMENT G.3 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)

Change financial institution (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

22. Will these payments be forwarded to a financial institution outside the United States? ................................................... YES NO If "YES," also complete the ACH (Direct Deposit) Payment Destination Confirmation (Form 74-227).

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) ividual Taxpayer Identification Number (ITIN) Social Security number (SSN)*

State employee Vendor or other recipient

2. Payee type

Texas Identification Number (TIN) Ind Employer Identification Number (EIN)

3. Identification number 4. Mail code (If not known, leave blank.)

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 from the state of Texas by direct deposit or to change/cancel existing direct deposit information.

Transaction Types

SE

C

TI

O

N

Payee Identification

SE

C

TI

O

N

New Account Information (Setups and Changes) (Completion by financial institution is recommended)

SE

C

TI

O

N

Existing Account Information (Changes Only)

SE

C

International Payments Verification (required)

SE

C

Authorization for Setup, Changes or Cancellation (required)

SE

C

TI

O

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-ments to my financial institution. I understand that any payments deposited in error to my account will be reversed by the agency that issues my state 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. (For further information on these rules, please contact your financial institution.)

Cancellation by Agency (for state agency use)

SE

C

State Agency Contact (for state agency use)

SE

C

TI

O

N

* See Federal Privacy Act Statement on page 2.

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 file about you. To request information for review or to request error correction, use the contact information on this form.

Section 1: Transaction Type(s)

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

Note: Requests to change custodial agency number are processed based on Payment Services research and guidelines.

Section 2: Payee Identification (Required)

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

Note: Agencies must complete box 34 with the appropriate agency’s return address for the selected payee type.

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) (Completion by financial institution is recommended)

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.

Section 5: International Payments Verification (Required)

22. Payment Destination: Select YES or NO to indicate if state payments will be forwarded to a financial institution outside the U.S.

Note: If YES, the payee must also complete the ACH (Direct Deposit) Payment Destination Confirmation (Form 74-227).

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: Disclosure of your Social Security number is required and authorized under law for the purpose of tax administration and identification of any individual affected by applicable law, 42 U.S.C. § 405(c)(2)(C)(i) and Tex. Gov’t Code §§ 403.011, 403.015, 403.055, 403.056 and 403.078. The Public Information Act, Tex. Gov’t Code Ch. 522, and applicable federal law shall govern release of information on this form in response to a public information request.