ESBD_File_345453_Exhibit G.4 - Direct Deposit Form.pdf

Direct Deposit Authorization

For Comptroller’s Use Only74-176 (Rev.4-14/18)

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Transaction Type

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)

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Cancellation by Agency (for state agency use) Reason Date

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International Payments Verification (required)

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).

Authorization for Setup, Changes or Cancellation (required)

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Authorized signature Printed name Date

I authorize the Texas Comptroller of Public Accounts to deposit my payments from the state of Texas to my financial institution electronically.

I understand that the Texas Comptroller of Public Accounts will reverse any payments made to my account in error.

I further understand that 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.)

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.

Signature Date

Phone number Agency number

Agency name

Comments

Authorized Signature (for state agency use)

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TEXAS COMPTROLLER OF PUBLIC ACCOUNTS

Fiscal Management - Direct Deposit Program P.O. Box 13528 Austin, TX 78711-3528

FAX: 512-475-5424 Phone: 512-936-8138

Please return your completed form to:

ext.

Financial institution name City State

Routing transit number (9 digits) Customer account number (maximum 17 characters) Type of account

Checking Savings Financial representative name (optional) Title (optional)

Financial representative signature (optional) Phone number (optional) Date (optional)

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

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Payee name Phone number

Mailing address City State ZIP code

Payee Identification

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Texas Identification Number (TIN) Employer Identification Number (EIN) Social Security Number (SSN)

Individual Taxpayer Identification Number (ITIN) State employee Vendor or other recipient ext.

Mail code (If not known, leave blank.)

Payee type

Routing transit number (9 digits) Customer account number (maximum 17 characters) Type of account

Checking Savings

Existing Account Information (Changes Only)

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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.

Form 74-176 (Back)(Rev.4-14/18)

Section 1: Transaction Type

Section 2: Payee Identification

Section 6: Authorization for Setup, Changes or Cancellation

Section 5: International Payments Verification

Section 7: Cancellation by Agency

Section 8: Authorized Signature

For state agency use only.

Provide reason for cancellation request.

For State Agency Use

Must be completed in its entirety, and no alterations to the authorization language will be accepted.

Check "YES" or "NO" to indicate if direct deposit payments to the account information designated in Section 3 of this form will be forwarded to a financial institution outside the United States. If "YES," also complete the ACH (Direct Deposit) Payment Destination Confirmation (Form 74-227).

Section 3: New Account Information (Needed for setups and changes)

Completion by financial institution is recommended.

Important: Your direct deposit account information may be different from the account information printed on your checks. It is recommended that you contact your financial institution to confirm your direct deposit account information.

Prenote Test:

A prenote test will be sent to your financial institution for the account information provided. The prenote test is for a period of six banking days, and it is sent to your financial institution to verify your account information. If no further action is required by your financial institution, your direct deposit instructions will become effective when the six banking day prenote time frame has expired.

Select payee type, provide the Texas Identification Number (TIN), Employer Identification Number (EIN) Social Security Number (SSN)* or Individual Taxpayer Identification Number (ITIN) and enter payee contact information.

*Federal Privacy Act Statement Disclosure of your Social Security number is required and authorized under law, for the purpose of tax administration and identifica-tion of any individual affected by applicable law, 42 U.S.C. sec. 405(c)(2)(C)(i); Texas Govt. Code Sections 403.011, 403.056, and

403.078. Release of information on this form in response to a public information request will be governed by the Public Information Act, Chapter 552, Government Code, and applicable federal law.

Select the appropriate transaction type(s).

Section 4: Existing Account Information (Needed for changes to existing account information)

When requesting a change to your existing direct deposit account information, you must complete Section 4 with the existing account information for verification purposes. This measure will help the paying state agency verify accuracy of the requested change.

Any change to banking information begins a prenote test period. See explanation in Section 3, above.

Accounts Payable/Direct Deposit Program 2200 West 35th Street, Bldg 10, Ste. JFTX-RA Austin, TX 78703-1222

Phone: 512-782-5657