PAYROLL AUTHORIZATION FOR DIRECT DEPOSIT

INTO EMPLOYEE’S ACCOUNT/ACCOUNTS

TREASURER AND RECEIVER GENERAL

Fax this form to the MassHR Employee Service Center

 Fax: 617-248-0686  Telephone: 617-979-8500 

SECTION 1: Employee Information


 

Employee Name:

     

Employee I.D:

     

Department:

     


 

SECTION 2:  Direct Deposit Information (fill in as necessary)

Instructions:  Direct deposits are distributed to accounts in order of the priority starting with priority ‘1’.  The total of the percentages cannot exceed 100%. 

Designate one (and only one) account to receive any excess funds left over after all direct deposits are processed.  Check ‘Partial Allowed?’ to allow the direct deposit amount to be less than the amount entered in the ‘Amount’ or ‘Percent of Net Pay’ fields.

If you are adding a new account, please list this along with all existing accounts in the order of priority.


 

Priority

Amount

 

Percent of Net Pay

Excess

(check 1)

Partial

Allowed?

*Transit #

Account #

Checking or Savings?

 

Leave

Alone

 

New

 

Change

 

Delete

1

$

     

or

     

%

 

     

 

     

 

     

 

2

$

     

or

     

%

 

     

 

     

 

     

 

3

$

     

or

     

%

 

     

 

     

 

     

 

4

$

     

or

     

%

 

     

 

     

 

     

 

5

$

     

or

     

%

 

     

 

     

 

     

 

6

$

     

or

     

%

 

     

 

     

 

     

 

7

$

     

or

     

%

 

     

 

     

 

     

 

8

$

     

or

     

%

 

     

 

     

 

     

 

9

$

     

or

     

%

 

     

 

     

 

     

 

10

$

     

or

     

%

 

     

 

     

 

     

 


 

SECTION 3:  Sign and Return to Your Payroll Coordinator

 

·      I choose to receive my bi-weekly payroll advice through the HR/CMS Payroll and Compensation – View Paycheck http://www.mass.gov/masshr and/or  the Commonwealth PayInfo website www.PayInfo.state.ma.us  (both available 24 hours). No bi-weekly paper copy will be issued to me by my employer


·         Check box if any of the total of any of the above direct deposits go directly to a foreign bank or if the entire amount is forwarded from a domestic bank to a foreign bank


·      I hereby authorize my employer, through the State Treasurer, to deposit my net pay and additional distributions, if any, to the financial institution(s) listed above.  My employer, through the State Treasurer, is also authorized to debit any over-deposit or error, which it has caused to be made to my account.  The State Treasurer or the employee may amend this authorization any time through HR/CMS self-service time and attendance or with proper notice to the Personnel/Payroll Office. In the absence of bank documentation, my signature certifies the Transit #(s) and Account #(s) indication above are correct as shown.


 

     

 

     

 

     

 

Employee Signature:

Date:

Employee Work Phone:


 

 

Changes made after the second Wednesday of the pay period may result in a paper check being issued for the affected portion of your wages for that 1 pay period.

 

*              NOTE:  to find the transit number, contact your financial institution for help.  Transit # is always 9 digits (all numeric) in length.                                                      Revised 9/23/13