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
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
PAY CARD AUTHORIZATION FORM (Sign Up or Cancel)
Page 2
Terms and Conditions
FEES ASSOCIATED WITH THE FOCUS CARD
Activity
Cost
Monthly Account Maintenance
Free
Purchases at Point-of-Sale (Domestic)
Free
Cash Back with Purchases (Domestic)
Free
1
ATM Transactions
Cash
Declined
Balance
Withdrawal
Withdrawal
Inquiry
U.S. Bank ATM
Free
Free
Free
MoneyPass
ATM
Free
Free
Free
®
Other ATM
$1.75
Free
Free
International ATM
$2.00
Free
Free
The owner of any Non-U.S. Bank or Non-
MoneyPass
ATM
may
assess
an
additional surcharge fee for any ATM
transaction that you complete.
Teller Cash Withdrawal
Free
Customer Service
Automated Phone Service
Free
Online
Free
Live Phone Representative
Free
2
Text or Email Alerts
Free
Inactivity
After 365 consecutive days (or a longer
$2.00 Per Month
period of time or never, as restricted
under applicable state law).
Not assessed if balance is $0.00.
Monthly Paper Statement
Free
Card Replacement
Standard Mail or Issued by employer
Free
(if applicable to your program)
Expedited Mail
$15.00
Foreign Transaction
Up to 3% of transaction amount
1
The first two cash withdrawals per month from any non-U.S. Bank ATM or non-MoneyPass ATM will
be free.
2
Standard messaging charges apply through your mobile carrier and message frequency depends on
account settings.
STANDARD LIMITS
To lessen the risk of loss due to fraud or theft U.S. Bank has the following daily dollar amount limits on the Focus
card:
Transaction Limits
Count
Amount
Maximum Card Balance
N/A
$40,000
Purchases (includes cash back)
20 per day
$4,000 per
transaction
Cash Loads (If applicable to your program)
3 per day
$950 per day
Teller Cash Withdrawal
5 per day
$5,000 per day
ATM Withdrawal
5 per day
$1,525 per day
Loads or Deposits
10 per day
$20,000 per day
Signature-based POS returns
4 per day
N/A
Pending ACH Credits
5 per day
$5,000 per day
ACH Loads
5 per day
$20,000 per day
We reserve the right to change the above fee schedule upon written notification to you as required by
applicable law.
For your own safety, we encourage you to use your card for transactions, rather than carrying large amounts of
cash. If you believe your use of the card will exceed the dollar limit for cash withdrawals, you can request a higher
limit for teller withdrawals from a financial institution. Complete the Authorization to Override Risk Limits box
beneath Section B. OSPS will request an exception for your card.
PAY CARD AUTHORIZATION
Page 3
STATEMENT FORMAT
Unless you request a paper form, you will receive an electronic statement through a secure website.
The website address will come with your card.
PRIVACY NOTICE
U.S. Bank collects name, date of birth, physical address, mailing address, and taxpayer ID number from its
cardholders. They cannot issue a Focus Card unless you supply this information. If provided, U.S. Bank will use this
information to verify your identity. They will not share it with other entities. See their privacy information below.
U.S. Bank pledges to maintain the privacy of your information by restricting access and maintaining physical,
electronic, and procedural safeguards to keep the information safe. (For the full text of the Bank’s Consumer
Privacy Pledge, see http://www.usbank.com/consumer_privacy.html. You will also receive a copy with your new
card.)
IF YOU HAVE NOT RECEIVED YOUR PAY CARD WITHIN 10 BUSINESS DAYS, CONTACT YOUR AGENCY’S
PAYROLL OFFICE.

Download Form OSPS.99.19 Pay Card Authorization Form - Oregon

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