Fillable Printable Direct Deposit Authorization Form - Texas
Fillable Printable Direct Deposit Authorization Form - Texas
Direct Deposit Authorization Form - Texas
Direct Deposit Authorization
For Comptroller’s Use Only
74-176
(Rev.4-14/18)
SECTION 1
Transaction Type
New setup (Sections 2, 3, 5 and 6) Change account type (Sections 2, 3, 4, 5 and 6)
Change financial institution (Sections 2, 3, 4, 5 and 6) Cancellation (Sections 2 and 6 - Sections 7 and 8 for state agency use)
Change account number (Sections 2, 3, 4, 5 and 6)
SEC 7
Cancellation by Agency (for state agency use)
Reason Date
SEC 5
International Payments Verification (required)
Will these payments be forwarded to a financial institution outside the United States? ......................................................... YES NO
If "YES," also complete the ACH (Direct Deposit) Payment Destination Confirmation (Form 74-227).
Authorization for Setup, Changes or Cancellation (required)
SECTION 6
Authorized signature Printed name Date
I authorize the Texas Comptroller of Public Accounts to deposit my payments from the state of Texas to my financial institution electronically.
I understand that the Texas Comptroller of Public Accounts will reverse any payments made to my account in error.
I further understand that the Texas Comptroller of Public Accounts will comply at all times with the National Automated Clearing House Association's
rules. (For further information on these rules, please contact your financial institution.)
This form may be used by vendors, individual recipients or state employees to receive payments
from the state of Texas by direct deposit or to change/cancel existing direct deposit information.
Signature Date
Phone number Agency number
Agency name
Comments
Authorized Signature (for state agency use)
SECTION 8
TEXAS COMPTROLLER OF PUBLIC ACCOUNTS
Fiscal Management - Direct Deposit Program
P.O. Box 13528
Austin, TX 78711-3528
FAX: 512-475-5424 Phone: 512-936-8138
Please return your completed form to:
ext.
Financial institution name City State
Routing transit number (9 digits) Customer account number (maximum 17 characters) Type of account
Checking Savings
Financial representative name (optional) Title (optional)
Financial representative signature (optional) Phone number (optional) Date (optional)
New Account Information (Setups and Changes) (Completion by financial institution is recommended.)
SECTION 3
ext.
Payee name Phone number
Mailing address City State ZIP code
Payee Identification
SECTION 2
Texas Identification Number (TIN)
Employer Identification Number (EIN)
Social Security Number (SSN)
Individual Taxpayer Identification Number (ITIN)
State employee
Vendor or other recipient
ext.
*
Mail code (If not known,
leave blank.)
Payee type
Routing transit number (9 digits) Customer account number (maximum 17 characters) Type of account
Checking Savings
Existing Account Information (Changes Only)
SEC 4
Instructions for Direct Deposit Authorization
You have certain rights under Chapters 552 and 559, Government Code, to review, request and correct information we have on
file about you. To request information for review or to request error correction, use the contact information on this form.
Form 74-176 (Back)(Rev.4-14/18)
Section 1: Transaction Type
Section 2: Payee Identification
Section 6: Authorization for Setup, Changes or Cancellation
Section 5: International Payments Verification
Section 7: Cancellation by Agency
Section 8: Authorized Signature
For state agency use only.
Provide reason for cancellation request.
For State Agency Use
Must be completed in its entirety, and no alterations to the authorization language will be accepted.
Check "YES" or "NO" to indicate if direct deposit payments to the account information designated in
Section 3 of this form will be forwarded to a financial institution outside the United States. If "YES," also
complete the ACH (Direct Deposit) Payment Destination Confirmation (Form 74-227).
Section 3: New Account Information (Needed for setups and changes)
Completion by financial institution is recommended.
Important: Your direct deposit account information may be different from the account information printed
on your checks. It is recommended that you contact your financial institution to confirm your direct deposit
account information.
Prenote Test:
A prenote test will be sent to your financial institution for the account information provided. The prenote
test is for a period of six banking days, and it is sent to your financial institution to verify your account
information. If no further action is required by your financial institution, your direct deposit instructions will
become effective when the six banking day prenote time frame has expired.
Select payee type, provide the Texas Identification Number (TIN), Employer Identification Number (EIN)
Social Security Number (SSN)
*
or Individual Taxpayer Identification Number (ITIN) and enter payee
contact information.
*Federal Privacy Act Statement
Disclosure of your Social Security number is required and authorized under law, for the purpose of tax administration and identifica-
tion of any individual affected by applicable law, 42 U.S.C. sec. 405(c)(2)(C)(i); Texas Govt. Code Sections 403.011, 403.056, and
403.078. Release of information on this form in response to a public information request will be governed by the Public Information
Act, Chapter 552, Government Code, and applicable federal law.
Select the appropriate transaction type(s).
Section 4: Existing Account Information (Needed for changes to existing account information)
When requesting a change to your existing direct deposit account information, you must complete Section
4 with the existing account information for verification purposes. This measure will help the paying state
agency verify accuracy of the requested change.
Any change to banking information begins a prenote test period. See explanation in Section 3, above.
