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<br />--- ,~ . <br />.w "; ~~~~_,6-s61~l <br /> <br />332-11 <br /> <br />fClrComptroller's U:Mcnty... - _ .,. . <br />I I"": . <br /> <br />DIRECT DEPOSIT AUTHORIZAi .IN <br />INSTRUCTIONS <br />. Use only BLU E 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 state agency. <br />. Check all appropriate box(es). <br />For further Instructions, see the back of this form. <br /> <br />z <br />o <br />;: <br />() <br />W <br />:JJ <br /> <br />o New setup <br />o Cancellation <br />o Interagency transfer <br />o Exemption <br /> <br />(Sections 2. 3 & 4) <br />(Sections 2 & 3) <br />(Sections 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 />(Sections 2, 3 & 4) <br /> <br />PAYEE IDENTIFICATION <br /> <br /> I. SClc.alSeCUfllYI"IUmberClr 0 0 2. Mail code (11 nor known, will ~ <br />N Feceral EmclClye(s IdenuhcallOn (FEll I I I I I I I I comp/ered by Payitlg Srate AgtNlcy) I I I I <br />z <br />0 3 Name 4. Business pl'\ClI"Ie number <br />;: ( ) <br />() <br />W 16. Cily 17.Slal& le.Z1Pcooe <br />Ul ~ Sueet aoaress <br /> <br />AUTHORIZATION FOR SETUP, CHANGES OR CANCELLATION <br /> <br /> 9. Pursuant to Section 403.016, Texas Government Code. I authorize the Comptroller of PubllcAccounts to deposit by electronic transfer payments <br /> owed to me by the State of Texas and, if necessary, debit entries and adjustments tor any amounts deposited 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 />0 .' <br />e: <br />() I consent to and agree to comply with the National Automated Clearing House Association Rules and Regulations and the Comptroller's rules about <br />"' <br />Ul electroniC transfers as they exist on the date of my signature on this form or as subsequently adopted. amended or repealed. <br /> tJ AUlncr,zeo 5,~nalure III. Prlnteclname 1 12.0ate <br /> <br />FINANCIAL INSTITUTION (Must be completed by financial institution representative.) <br /> <br /> 'j ~.ame !14.Clty !15.S18le <br /> .., .~ Rout,nglral"l$'! numoer ' 17. Customer accounl number (Dashes requltfla DYES) J jle. Type 01 account <br /> 2 - - ! I I 0 Checking o Savings <br /> g I I , , I I LJ I I I I I I I I I I , I I I I I <br /> .... 1 q ~p.ore5en!.1l,ve name (Please ,"'nil 20 r,lIe <br /> () <br /> W <br /> <1) <br />, 2 t P~o'e50!nTall..e sl9nalure /Oatlonall j rPhClnenUmOr 1 23.0at8 <br />i <br /> <br />EXEMPTION: <br /> <br /> I claim exemption and request payment by state warrant (check) because: <br />on 24.01 hold a position that is classified below group 8 in the position classification salary schedule. <br />z 25. 0 I am unable to establish a qualifying account at a financial institution. <br />0 <br />e: 26. 0 I certify that payment by direct deposit would be impractical and/or more costly to me than payment by warrant. <br />() <br />w 12e. Printed name 129.oale <br />'Il 27 Aut"'o:l"zeQ s'gnalure <br /> <br />CANCELLATION BY AGENCY <br /> <br />[[1'0 R",," <br /> <br />I". d... <br /> <br />PAYING STATE AGENCY <br /> <br />~2 S'?naIUre <br /> <br />33. Pritlledname <br /> <br />... <br />Z <br />o 34 Agency name <br />;: <br />() <br />W <br />r.n ~6 CommenTS <br /> <br /> <br />135.~enc:ynumoer I <br /> <br />38. Dale <br /> <br />WHITE - Comptroller <br /> <br />YELLOW. Agency <br /> <br />PINK. Payee <br />