Fillable Printable Direct Deposit Application Form - Tennessee

Direct Deposit Application Form - Tennessee

TATE OF

ENNESSEE

AYROLL

EQUEST

Direct Deposit Authorization

FA-0722 (08/08)

Please return completed form to the Finance & Administration Central Payroll office. Date:

Employee Name:

Work Phone:

Empl ID

Last four digits of Social Security Number:

Direct Deposit Instructions:

Direct deposits are distributed to accounts in order of the priority indicated starting with priority ‘1’. If only one banking institution is set up,

Section A will designate the account to receive 100% of net pay. If there are multiple banking instructions in Section B, then Section A will

be the designated account to receive any remaining funds after all other direct deposits are processed. The last priority will be established for

that account.

Section A: Balance Account: The following account is either the only account to be used for Direct Deposit or the account which is to

receive the net amount remaining after all other deposits have been made as indicated in Section B, the list of Additional Accounts. Non-

payroll amounts, such as travel or flexible benefit reimbursements will be deposited into the account designated in Section A.

Balance

Routing / Transit # Account # Checking Savings

Bank Name:

Section B: Additional Accounts For Multiple Direct Deposits: A priority and a flat amount must be designated for any additional

accounts listed below.

Priority Flat Amount Routing / Transit # Account # Checking Savings

Bank Name:

Priority Flat Amount Routing / Transit # Account # Checking Savings

Bank Name:

I hereby authorize the State of Tennessee to deposit my net pay to the financial institution(s) listed above, and to deposit all non-payroll

amounts due to me into the account designated in Section A - Balance Account. In the event funds to which I am not entitled are deposited

to my account(s), I hereby authorize the State of Tennessee to direct the bank to return said funds. I understand this agreement may be

terminated by me upon proper execution of another authorization agreement.

I further understand that if any of the bank account(s) listed are closed, I will not get paid on time; my pay will be delayed.

I understand that this transaction will be processed within 30 working days upon receipt of this form in Finance & Administration

Central Payroll. I further understand that a paycheck will be mailed to me on the first payday after this transaction has been

processed; the following payday, my payroll will be deposited into my new account.

Employee Signature:

Date:

A COPY OF A VOIDED CHECK OR STATEMENT FROM FINANCIAL INSTITUTION

SHOWING THE ACCOUNT NUMBER AND ROUTING/TRANSIT NUMBER FOR EACH ACCOUNT MUST ACCOMPANY

THIS FORM

Mail completed and signed form TN Finance and Administration

along with voided check to: Central Payroll

15th Floor TN Tower

312 Rosa L Parks Ave.

Nashville, TN 37243

Or fax to: 615-253-4167

TATE OF

ENNESSEE

AYROLL

EQUEST

Direct Deposit Authorization

FA-0722 (08/08)

To sign up for direct deposit or make a change, log onto the Employee Self Service (ESS) at

please contact the Central Payroll Call Center at 615-741-7243 or toll-free 1-877-944-3873.

If you cannot access ESS, please follow the instructions below to submit your direct deposit information and/or

changes to the Central Payroll office.

Please complete all information requested on the Direct Deposit Authorization Form. For Checking Accounts,

please attach a copy of a voided check. For Savings Accounts, please obtain and submit a statement from your

financial institution showing the account number and routing/transit number. The accuracy of the direct deposit

information provided is very important.

A copy of a voided check may not provide the correct data for Credit Union accounts. Please contact your

Credit Union directly to obtain the correct routing/transit and account numbers to be used for Direct Deposit.

If you designate only one account

Complete Section A - Balance Account only. All of your net pay will be direct deposited to the designated

account.

If you have multiple direct deposit accounts

Complete Section A - Balance Account and Section B - Additional Accounts for Multiple Direct Deposits

with the other direct deposit instructions. Indicate the priority (10 for first priority and 20 for second priority)

and the flat amount to be deposited into each of the listed accounts. The remaining balance will be deposited

into the account listed in Section A. Any non-payroll amounts such as travel or flexible benefit reimbursements

will be deposited into the account listed in Section A.

Note: Only list a financial institution once. If you have multiple accounts with the same financial institution,

make arrangements with the financial institution to distribute the funds appropriately.

A prenotification (pre-note) will be initiated to your financial institution(s) prior to making deposits based on

this authorization. The pre-note process is a zero dollar entry transmitted to your financial institution(s) for the

purpose of verifying the accuracy of the account and routing/transit numbers provided and entered into the

payroll system. Each new or changed Direct Deposit instruction will cause that account to go through the pre-

note process for one pay period. Each time you add a new or change an existing account, complete a new Direct

Deposit Authorization Form with all account information to replace any previous instructions.

If you change or close one or more of your Direct Deposit accounts, you must notify your employer

immediately and complete an authorization form with your new account information so it can be entered into

the payroll system before the next pay period. This will prevent your Direct Deposit from being transmitted to a

“closed account” on payday. Failure to promptly notify your employer of changes to your Direct Deposit

information will cause a delay in receiving your total net pay. The receiving bank must return funds sent to a

closed account to the State of Tennessee before a replacement check can be reissued to the employee.

http://edison.tennessee.gov and click on the Direct Deposit link on “My Page”. If you have any questions,