AC 2772 (Rev. 8/07)
PLEASE SEE REVERSE SIDE FOR INSTRUCTIONS
Direct Deposit Form for NYS Employees
(To be used for enrollment, changes and cancellations)
Section A: Employee Information
NAME (LAST, FIRST, MI) ________________________________________________ WORK PHONE # ( ) ____________
LAST FOUR DIGITS OF SOCIAL SECURITY # __ __ __ __ AGENCY/DEPT CODE __ __ __ __ __
For more than three accounts or if you prefer to list each Financial Institution on a separate form, use additional forms as necessary. Up to seven fixed
amount or percentage deposits may be processed as well as one excess (net pay) deposit.
Section B: Account Type
*For new/additional accounts with joint account holders or to add a joint account holder to existing accounts, both signatures are required in Section D.
Section C: This section must be completed by your financial institution for new/additional accounts when directing
funds into a savings account or into a checking account if a voided personal check is not attached. The employee’s
name MUST appear on the account(s).
As a representative of the below named financial institution, I certify that this institution is ACH capable and agree to receive and deposit the salary to
the account shown above in accordance with Part 102 of the Codes, Rules, and Regulations of the State of New York and to be bound by such rules.
Salary credited to the account below will be available to the depositor on payday.
1. NAME OF FINANCIAL INSTITUTION __________________________________________ Account Type
Depositor’s Account Number (EFT Format)