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<br />ATTACHMENT 2-2 <br /> <br />~ .>.- ".,.. <br />~ t:=' ,(Rev. 6-9&'5) <br /> <br /> <br />DIRECT DEPOSIT AUTHORIZATION <br /> <br />INSTRUCTIONS <br />. Use only BLUE or BLACK ink. <br />. Alterations must be initialed. <br />. Financial institution must complete Section 4. <br />TRANSACTION TYPE <br /> <br />. Section 7 must be completed by the paying slate agency. <br />. Check all appropriate box(es). <br />For further instructions, see the back of this form. <br /> <br />(') <br />, .' <br /> <br />z <br />o <br />i= <br />u <br />w <br />Ul <br /> <br />[2g New setup <br />o CanceUation <br />o Interagency transfer <br />o Exemption <br /> <br />(Sections 2, 3 & 4) <br />(Sections 2 & 3) <br />(Seclions 2 & 3) <br />(Sections 2 & 5) <br /> <br />o Change financial institution <br />o Change account number <br />o Change account type <br /> <br />(Sections 2. 3 & 4) <br />(Sections 2, 3 & 4) <br />(Secrions 2. 3 & 4) <br /> <br />PAYEE IDENTlACATlON <br /> <br /> 1. SociIiIII Socuqy numb<< 0( wg7 31 5 CBI 2.Mailc:0d8tttnQfk/looon,wiJloe I <br />N Federal Empq.er's ldenlific:alion (FEI) I 51 61 01 0 016 I compIBted by P.ytIg Sr.,. Agency} I I I <br />z <br />0 3. Name 4. 8usness ~_Det <br />i= City of Paris ( 903 )785-7511 <br />u <br />w 10."", Paris 17.~~. 187~46'i_9037 <br />Ul 5.su....~85S <br /> P:O. Box 9037 <br /> <br />AUTHORIZATION FOR SETUP, CHANGES OR CANCELLATION <br /> <br />9. Pursuant to Section 403.016. Texas Government Code, I authorize the Comptroller of Public Accounts to deposit by electronic transfer payments <br />owed to me by the State of Texas and, << necessary, debit entries and adjuS1lllents for any amounts depos~ed electronically in error. The Comptroller <br />(") shall deposit the payments In the financial institution and account designated below, I recognize that if I fail to provide complete and accurate informa- <br />z tion on this authorization form, the processing of the form may be delayed or that my payments may be erroneously transferred electronically. <br />o <br />i= <br />u <br />w <br />Ul <br /> <br />I consent to and agree to comply with Ihe National Automated aaaring House Association Rules and Regulations and the Comptroller's rules about <br />electronic transfers as they exist on the date of my signabJre on this form or as subsequently adopted. amended or repealed. <br /> <br />10.Au1hor1uclsignal..... ~~~ <br /> <br /> <br />".PrWlled~ <br />W,E. Anderson <br /> <br /> <br />", <br /> <br />FINANCIAL INSTITUTION (Must be completed by financial institution representative.) <br /> <br />'3. Name <br />Liberty National 8ank ofrparis <br /> <br />'''.City <br />Paris <br /> <br /> <br />15,Swe <br /> <br />TX <br /> <br />.., 16. ~Iransilrunber <br />Z <br />o I I ,I ,I I q I-I 0 I 01 5, 71-Lftj <br />i= <br /><> <br />w <br />Ul <br /> <br />~ 7 . CUSlOl1let KCOunC numbeI <br /> <br />(OltsIW$ ff/lQUir<<l <br /> <br />YES, <br />, 11..,21(,17 Ii <br /> <br />'8. TJ$M 01 aetlO\.If'IIo <br />g Checking 0 Savings <br /> <br /> <br />'- <br /> <br /> <br />New Account <br /> <br /> <br />.JJc: <br /> <br />) 785-7651 <br /> <br /> I claim exemption and request payment by stale warrant (check) because: <br />'" 24. 0 I hold a position that is dassified below group 6 in the position dassification salary schedule. <br />z 25. 0 I am unable to establish a qualifying account at a financial inslilUtion. <br />0 <br />i= 26, 0 I certify that payment by direct deposit would be impractical and/or more cosny 10 me than payment by walTant. <br />U <br />w 128. Printed flame 1 29,Oal. <br />Ul 27. Authorized Sign.lute <br /> <br />CANCELLATION BY AGENCY <br />[i] 30. ..,... <br /> <br />131.0'" <br /> <br />PAYII'IG STATE AGENCY <br /> <br />32, SognalUI. <br /> <br />JJ Prll'll80 name <br /> <br />" <br />Z <br />o 34. AgtIOCy name <br />;:: <br /><> <br />W <br />C/) 36 Comm..m <br /> <br />35 A9&ncr "umDltr <br />I <br /> <br />37 Phone numtle. <br /> <br />38.0.111 <br /> <br />) <br />