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OCF-3 (2/29/2004) COUNTY OF OTSEGO PAYROLL DIRECT DEPOSIT AUTHORIZATION (ELECTRONIC FUNDS TRANSFER) Please Print or Type Type of application (Select One Only) NEW: Complete step 1 and step 2 then forward this form to Human Resources. Allow at least two pay periods before your payroll direct deposit begins. Your direct deposit is in effect when you receive a Statement of Earnings and Deductions with the name of your bank to the left of your net pay amount instead of a payroll check. CHANGE: When changing your financial institution, Account Number or type of account, you must complete a new application. Complete step 1 with all updated information, then complete step 2. Forward this completed form to Human Resources after you obtain all required signatures. Your direct deposit will be suspended and a payroll check will be issued while your new account information is being verified. The remittance portion of your check will contain your payroll information. Do not close any accounts until you receive a payroll deposit in your new account. CANCELLATION: Complete step 2 and forward this form to your Human Resources. A cancellation should take effect within two pay periods of your request. Do not close your old accounts until you receive a payroll check. Name (Last, First, MI) Department Dept No (if known) 1. Attach a voided check below and complete financial institution information. Then complete step 2. Write VOID on an unused check and attach here NOTE: The sample check to the right shows where your Routing Transit Number and Account Number may be found on your personal check. A. Name of Financial Institution FOR HUMAN RESOURCES USE ONLY Entered By: Date: C. Account Number - The Account Number can be up to 17 characters. Omit hyphens, spaces, and special symbols. Enter the number from left to right and leave any unused boxes blank (see sample above). B. Routing Transit Number Must be nine digits (see sample above). 2. Enter your account type and your Social Security Number below. Obtain and attach secondary signature(s) if necessary. Sign the bottom of this form and return to Human Resources office. (Select one only) Social Security No. Employee ID No Checking Savings I authorize the County of Otsego to deposit the net pay owed me by the County, by direct deposit (electronic funds transfer) into the designated financial institution and Account Number. I understand this authorization remains in effect until revoked (cancelled) by: me, my death or legal incapacity, the financial institution, the County of Otsego or my separation. I authorize the County of Otsego to recover money electronically deposited in my account in error, either by adjusting or debiting the account, or withholding future payments. I understand I will be notified by the County of Otsego if adjustments or debits are being made. I consent to and agree to comply with the National Automated Clearing House Association Rules and regulations and the County of Otsego's rules about electronic funds transfers as they exist on this date or as subsequently adopted, amended or repealed. Michigan law governs electronic funds transactions in all respects except as otherwise superseded by federal law. If more than one signature is required to authorize withdrawals of funds, all must sign this form before you submit it. Attach a page with secondary signatures if necessary. Employee Signature Date Work Phone ( ) - Home Phone ( ) - Secondary Signature Date Work Phone ( ) - Home Phone ( ) - Richard and Cindy Jones 123 Main Street Anytown, MI 49111 1800 $ 20 Pay to the Order of VOID ANYTOWN BANK Anytown, MI 49111 For I:012345678I: 012312312312II ▪ 1800 Routing Transit Number Account Number