STATE OF MARYLAND
STATE OF MARYLAND
PAYROLL DIRECT DEPOSIT AUTHORIZATION
PAYROLRegular
L DIRECT DEContract
POSIT AUTH
ORIZATION
Payroll System (Check one)
University of Maryland
Regular
Payroll System (Check one)
Social Security Number
Social Security Number
Agency Code
Agency Code
3
6
--
0
2
University of Maryland
Employee’s Name (please print)
Employee’s Name (please print)
-3
Contract
Agency Name (please print)
Agency Name (please print)
0
University of Maryland University College
I authorize the State of Maryland Central Payroll Bureau to take the following action with my net salary:
I authorize the State of Maryland Central Payroll Bureau to take the following action with my net salary:
(Check One)
CPB Use Only
(Check One)
CPB Use Only
1. Initiate Deposit directly to my checking/savings account
1.(Will
Initiate
my checking/savings
account
takeDeposit
at least directly
two paytoperiods
to allow for pre-note
process.)
(Will take at least two pay periods to allow for pre-note process.)
2. Change account type(checking/savings account), and/or bank routing number to which my net salary
2.isChange
account
type(checking/savings
account),
and/or
bank
which
net salary
deposited
(cancel
of old account will occur
within
21 days
forrouting
receiptnumber
of CPB;toyou
willmy
receive
deposited
(cancel
of old
occur within 21 days for receipt of CPB; you will receive
aispayroll
check
until the
newaccount
accountwill
is established)
a payroll
check
until the
newpayroll
account
is established)
Do
not close
account
until
check
is issued.
Do not close account until payroll check is issued.
3. Discontinue direct deposit into my checking/savings and issue a payroll check instead.
3.Do
Discontinue
direct deposit
my checking/savings
not close account
until into
payroll
check is issued. and issue a payroll check instead.
Do not close account until payroll check is issued.
Bank Name:
(Omit
if action
3 is checked)
Bank
Name:
Processed by:
Processed by:
(Omit if action 3 is checked)
Account Type: (Must Check One)
Type
(Must
One)
IfAccount
not marked this
form: will
be Check
returned
If not marked this form will be returned
Effective PPE:
Effective PPE:
Checking
Checking
Savings
Savings
Bank Number
Bank Number
Checking/Savings Account Number
Checking/Savings Account Number
IAT requirement
IAT requirement
Verify carefully. For checking copy directly from your personal check. Do not
Verify carefully.
Fornumber.
checkingDo
copy
yourslip
personal
check. Do not
include
your check
not directly
use yourfrom
deposit
number.
include your check number. Do not use your deposit slip number.
Check box if your full net pay is subsequently transferred to a foreign bank.
Check box if your full net pay is subsequently transferred to a foreign bank.
I authorize the State of Maryland to deposit my net salary to the bank and account named above. This authorization is to remain in force until the State of
Maryland
receives
written
notification
from me
itssalary
termination
in time
manner
that allows
State
and the bank
opportunity
act upon
I authorize
the State
of Maryland
to deposit
myofnet
to the bank
andand
account
named
above.the
This
authorization
is toa reasonable
remain in force
until thetoState
of it.
InMaryland
the eventreceives
that the written
State ofnotification
Maryland notifies
theofbank
that funds to
I am
not entitled
have the
beenState
deposited
my account
in error,
I authorize
directit.
from me
its termination
in which
time and
manner
that allows
and thetobank
a reasonable
opportunity
to and
act upon
the
to return
saidState
funds
the Statenotifies
as soonthe
as possible.
the funds
erroneously
to my
account
havetobeen
that account
so that
In bank
the event
that the
oftoMaryland
bank thatIffunds
to which
I am not deposited
entitled have
been
deposited
my drawn
accountfrom
in error,
I authorize
and direct
return
of those
funds
by funds
the bank
to the
State
is notaspossible,
authorize
theerroneously
State to recover
thosetofunds
by setting
offbeen
the amount
erroneously
paid me
from
the bank
to return
said
to the
State
as soon
possible.I If
the funds
deposited
my account
have
drawn from
that account
so that
any
future
payments
thebank
Statetountil
amount
of the erroneous
deposit
has been
recovered,
full. by setting off the amount erroneously paid me from
return
of those
fundsfrom
by the
the the
State
is not possible,
I authorize
the State
to recover
thoseinfunds
any future payments from the State until the amount
of the erroneous deposit has been recovered, in full.
_________________________
__________________________________
_________________________
_________________________
Date
Date
Instructions:
__________________________________
Employee signature
Employee signature
_________________________
Daytime phone number
Daytime phone number
• Instructions:
Only one account is permitted for direct deposit. You can choose either checking or savings not both.
• •Type
print
only (except
signature).
Onlyorone
account
is permitted
for direct deposit. You can choose either checking or savings not both.
• •Use
black
ink only.
Type
or print
only (except signature).
• •Complete
blocked
Use blackallink
only. areas in the top part of form except for the section “CPB use only.”
• •Read
authorization
andareas
sign the
completed
Unsigned
or the
Incomplete
formsuse
willonly.”
be returned.
Complete
all blocked
in the
top part form.
of form
except for
section “CPB
• •Deposit
amount will and
be full
of pay
intoUnsigned
either your
Read authorization
signnet
theamount
completed
form.
orchecking/savings
Incomplete formsaccount..
will be returned.
• •IfDeposit
changing
your account
type,
and or
youchecking/savings
will receive a payroll
check until new direct deposit becomes effective.
amount
will be full
netbank
amount
of account
pay into number,
either your
account..
• •Do
not send ayour
voided
blanktype,
check.
If changing
account
bank and or account number, you will receive a payroll check until new direct deposit becomes effective.
• •Send
completed
form toblank
Central
Payroll Bureau, P.O. Box 2396, Annapolis, MD 21404. Phone 410-260-7401.
Do not
send a voided
check.
• Send completed form to Central Payroll Bureau, P.O. Box 2396, Annapolis, MD 21404. Phone 410-260-7401.
CPB/c/dd/0059/2-2010