Electronic Funds Transfer Form printable pdf download

ELECTRONIC FUNDS TRANSFER FORM

Purpose: This form will permit a SCCD employee to have their employee paycheck directly

deposited to their personal bank account.

Employee Instructions: 1. Complete the upper portion of this form, sign, and date.

2. Attach a voided check or deposit slip from your bank

account to this form (staple to form and mark VOID

on the check).

3. Send completed form to the Payroll Dept. 1D0100.

IMPORTANT NOTE: Your next check issued after the Electronic Funds Transfer

information is entered or changed in the computer will not be deposited. Instead a pre-

note (testing transaction) will be sent to the bank so they have a chance to verify the

numbers. If the pre-note test is successful then on your next pay day you will receive an e-

message reminding you that you have been paid.

Employee Last Name

First Name

Initial

Social Security Number

Employee Street Address

City

State

Zip code

Home Phone

E-mail (Required to receive Advice Notification)

In accordance with RCW 43.08.085, I hereby authorize and request the State, until this

authorization is revoked as described below, to transfer the full amount of my state salary, after

mandatory and authorized deductions, to the designated financial institution for deposit in my:

Savings Account (mark “X” in appropriate box)

Checking Account

ATTACH (STAPLE) A VOIDED CHECK OR DEPOSIT SLIP FROM THE PERSONAL

BANK ACCOUNT YOU WILL BE USING FOR DIRECT DEPOSIT.

In the event that the State may be legally obligated to withhold any additional part of my salary

payment for any reason, I understand that the State shall have the authority to immediately

terminate any transfer made under this authorization.

In the event that the exercise of this authorization for any reason results in an overpayment of

salary wages actually due and payable to me, I hereby authorize the State to either:

1. Withhold a sum equal to the overpayment from my next state salary payment; or

2. Debit my above-identified checking or savings account for an amount not to exceed said

payment.

This authorization is in force until written notification is received from me regarding its termination,

or my death. This authorization will not be in effect for any payments made on or after separation

from state service.

EMPLOYEE’S SIGNATURE

DATE

Revised 11/16/2004

Electronic Funds Transfer Form