STATE OF MINNESOTA

PAYROLL DIRECT DEPOSIT AUTHORIZATION	 New to direct deposit program	
	 Add/change/delete existing direct deposits	
	 Stop all direct deposit effective:      
      (Used only for Finance-approved exceptions)	
Employee ID
     	Employee name (last, first, middle initial)
     	Agency name
     	Work Phone
     	
Action	Priority #
(e.g. 1,2,3)	Bank ID Number*
(9 digits)	Account Number*
(up to 17 characters)	Deposit Type 	Account Type*	
 Add
 Change
 Delete	  	     	     	  Amount  $       
  Percent  %       
  Balance	 Checking
 Savings	
Effective Date
     	Financial institution (name, city, state)
     	
Action	Priority #
(e.g. 1,2,3)	Bank ID Number*
(9 digits)	Account Number*
(up to 17 characters)	Deposit Type 	Account Type*	
 Add
 Change
 Delete	  	     	     	  Amount  $       
  Percent  %       
  Balance	 Checking
 Savings	
Effective Date
     	Financial institution (name, city, state)
     	
Action	Priority #
(e.g. 1,2,3)	Bank ID Number*
(9 digits)	Account Number*
(up to 17 characters)	Deposit Type 	Account Type*	
 Add
 Change
 Delete	  	     	     	  Amount  $       
  Percent  %       
  Balance	 Checking
 Savings	
Effective Date
     	Financial institution (name, city, state)
     	
IF YOU SELECTED CHECKING ACCOUNT, ATTACH A VOIDED CHECK TO THIS FORM.  IF YOU SELECTED SAVINGS ACCOUNT, ATTACH A DEPOSIT SLIP TO THIS FORM.
(NOTE: DO NOT ATTACH THE DEPOSIT SLIP IF IT DOES NOT HAVE PRE-PRINTED BANK AND ACCOUNT NUMBERS.)	
*  Adding a new direct deposit or changing account type, bank identification number or account number requires a prenote to be sent to the bank before the add or change becomes affective. A prenote sends your account type, bank ID and account number to the bank to assure the accuracy of the numbers. Changes should be effective 5 to 15 days after the agency enters the direct deposit in the payroll system. You will receive warrants until the prenoting process is complete.
Remarks 
      	
I authorize the Department of Finance and my financial institutions indicated above to initiate electronic credit entries (direct deposit) of the amounts I designated and if necessary, debit entries and adjustments for any credit entries made in error to my accounts as I indicated above.  I understand that this authorization will cause any previously authorized direct deposits to financial institutions to be discontinued.
Employee Signature

	Date
	
FI-00381 06/03                           Send this form to your agency direct deposit designee.  If you are not sure who this is, contact your payroll or personnel office.

Payroll Direct Deposit Authorization Form Instructions

Boxes In The Upper Right-Hand Corner Of Form: Check the applicable box. To stop all direct deposits based on a Finance approved exception, check the stop box and sign and date the form.

Priority Number: Indicate which direct deposit account should receive funds first, second, or third.

Bank ID Number and Account Number: If you are not sure what these numbers are, contact your financial institution. Credit unions may not have the correct bank ID number and account number needed for direct deposit printed on their checks. If applying for direct deposit to a credit union, contact the credit union for the numbers and for the type of account to select. (These numbers are correct on Affinity Plus Federal Credit Union and Hiway Federal Credit Union checks.)

Deposit Type: Select amount, balance or percent.  Fill in the amount or percent(%). There must be one distribution with balance selected, or a distribution of 100%.

Account Type: If you have accounts other than checking or savings (such as a loan), ask your financial institution which type of account to select.

Percent Of Net Pay Or Dollar Amount: Each direct deposit must have either a percent of net pay or a dollar amount, except for Deposit Type Balance. 

Effective Date: If the information you provide is correct, your direct deposit will be effective approximately 5 to 15 business days after the agency enters the direct deposit in the payroll system. Deposits will be in accounts sometime on payday (usually Friday). The financial institution must post the deposit on payday, but may do so anytime on payday. Even if the financial institution posts it early on payday, a few automatic teller machines (ATMs) may not register the deposit until the day after payday. Ask your financial institution when the deposit will be available. If you have a problem with a deposit on payday (i.e., the ATM does not reflect the deposit), ask the direct deposit representative at your financial institution when it will post the deposit.

Direct Deposit Distribution Examples :

Example 1:	Priority 1 - 75% of net pay to checking, Priority 2 - 25% of net pay to savings, Priority 3 – Balance to same account as savings.
•	If net pay is $500.00, the checking deposit will be $375.00 and the savings deposit will be $125.00.
•	Any excess balance will be deposited into the savings account.

Example 2:Priority 1 - $300.00 to checking, Priority 2 - $200.00 savings, Priority 3 – Balance to same account as checking.
•	If net pay is $500.00, the checking deposit will be $300.00 and the savings deposit will be $200.00. 
•	If net pay is $550.00, the checking deposit will be $350.00 and the savings deposit will be $200.00. 
•	If net pay is $100.00, the checking deposit will be $100, and there will be no savings deposit. 

Notice: All data on this form is private data, in accordance with Minnesota Statute 13.43, except for employee name, employee ID number, agency name and work phone. The private data is not legally required; however, by not providing it, your direct deposit transaction will not be assured of going to the correct financial institution, to the correct account or that the correct amount will be posted accurately. The private data listed on this form is available to representatives of your agency and employees of the State who perform personnel or payroll related functions, provided such individuals have a business reason to access the data. Others who may legally access this information are representatives of the Attorney General and Legislative Auditor, enforcement agencies with statutory authority and persons/entities authorized by law or court order.