Form OSPS.99.19 Pay Card Authorization Form - Oregon

Form OSPS.99.19 or the "Pay Card Authorization Form" is a form issued by the Oregon Department of Administrative Services.

The form was last revised in May 1, 2016 and is available for digital filing. Download an up-to-date fillable Form OSPS.99.19 in PDF-format down below or look it up on the Oregon Department of Administrative Services Forms website.

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PAY CARD AUTHORIZATION FORM
(SIGN UP OR CANCEL)
U.S. Bank Focus® MasterCard®
I Want To:
START using the pay card (Complete Sections A through C)
CHANGE dollar amounts (Complete Sections A-ID# & Name, B-Change, and C)
STOP using the pay card (Complete Sections A- ID# & Name and D)
INSTRUCTIONS TO
Section A: About Me
EMPLOYEES:
Employee ID Number: (Please do not use your Social Security number here.)
1. Complete this form
OR __ __ __ __ __ __ __
(Don’t know this? Find it on your paystub, or ask payroll to help.)
online at
Name: First
Name: Last
http://go.usa.gov/33J
.
2. Read the Terms and
Physical Address:
Conditions on Page 2.
3. Print, sign, and give to
City:
State:
ZIP Code:
your agency payroll
office.
Allow at least one
NOTE:
Mailing Address same as Physical Address
full pay cycle for set-up.
Mailing Address:
City:
INSTRUCTIONS TO
PAYROLL OFFICES:
State:
Zip Code:
Date of Birth:
Social Security Number:
1. See the Entry Guide,
__ __ / __ __ / 1 9 __ __
__ __ __ - __ __ - __ __ __ __
Direct Deposits for
complete instructions.
Section B: About My Deposit
2. Enter Focus in the P070
NEW
DEPOSITS
CHANGE
DEPOSIT AMOUNTS
COMM field.
Deposit my entire pay after deductions
Old Amount:
$
3. Complete the “Agency
Deposit fixed amount each month
Contact” portion of this
Amount: $______________________
New Amount: $
form and fax to OSPS
(503-378-3518).
Section C: Authorization
4. When completed, this
OPTIONAL: Authorization to Override $ Limits:
OPTIONAL: Override Statement Default:
form is Information Asset
I acknowledge the risk of raising the
I acknowledge the risks associated with
Classification Level 3 as
standard limits as outlined on Page 2 of this
paper statements and choose to receive
defined by the Enterprise
form for cash withdrawals, and request my
Security Office.
my statement through U.S. mail.
daily teller withdrawal limit be raised to
5. Refer to the Secretary of
Initials: ______
$___________. Initials: ______
State, Archives Division
Administrative Rules for
Important! Please read and sign before submitting:
I authorize the State of Oregon to
retention guidelines.
deposit payments and make overpayment adjusting debits to my pay card. I have read and understand
the information contained on all pages of this form. I understand that direct deposit transactions must
FOR AGENCY USE:
comply with federal and state laws. I authorize the State of Oregon to share the information on this
XDNN
Entry Date
Initials
form with U.S. Bank, N.A. I also understand that when I start using the pay card, I am agreeing to be
Plan Code
bound by the Cardholder Agreement that I will receive with my card.
Date Pre-Note
Date Live
Signature: ___________________________________________ Date: _________________
OSPS Use Only
Section D: Cancel Authorization
(SKIP THIS IF NOT CANCELLING)
NOTE: Complete the “Name” and “Employee ID Number” fields in Section A.
Received Date Stamp
I hereby revoke my previous authorization for direct deposit to this pay card:
Signature: ___________________________________________ Date: ________________
Section E: Agency Contact (for Agency Use Only)
Agency Number
Contact Name (Please PRINT or TYPE)
For OSPS Use Only
Revised 05/2016
Verify to P070
Web Entry | Initials:
.
Form No. OSPS.99.19

Download Form OSPS.99.19 Pay Card Authorization Form - Oregon

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