"Direct Deposit Enrollment Form" - Nebraska

Direct Deposit Enrollment Form is a legal document that was released by the Nebraska Department of Administrative Services - a government authority operating within Nebraska.

Form Details:

  • Released on April 4, 2016;
  • The latest edition currently provided by the Nebraska Department of Administrative Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Nebraska Department of Administrative Services.

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Direct Deposit Enrollment Form
Name ________________________________ Address book # ______________ Agency # ______
(Please check one: Beginning new deposit ___ or changing existing information ___)
Pursuant to State of Nebraska Accounting policy (#41 & #42), payments for all wages. stipends and expense reimbursements will be
made by electronic funds transfer (EFT/Direct Deposit) to your choice of a financial institution or to a state authorized debit card.
You must enroll into the electronic funds transfer system if you are to receive any of these payments.
Payroll or Stipend Payment:
If you are an employee receiving wages or if you receive a stipend per your appointment, please complete
the table below with the appropriate direct deposit information.
If you are choosing the Focus Debit card option, complete the Focus Debit Card Sign-up Form; enter US
Bank in the Bank Name column and leave the account information blank.
Account Information
(S)aving or
Method
$ or %
(C)hecking
Code
Amount
Bank Name
Routing Number
Account Number
Method Codes: $ - Flat amount, % - percent of net pay deposited, R - Remainder of net for deposit
Expense Reimbursement Payment:
The following Expense Reimbursement information is separate from your payroll/stipend information and must be
completed to process the electronic transfer of your reimbursement.
Please complete the table below with the appropriate direct deposit information.
If you are choosing the Focus Debit card option, complete the Focus Debit Card Sign-up Form; enter US
Bank in the Bank Name column and leave the account information blank.
Account Information
(S)aving or
Method
(C)hecking
Code
Bank Name
Routing Number
Account Number
E
Attachments Required:
When providing new account information for direct
deposit, attach one of the following items for
verification:
• Blank check (voided)*
• Photocopy of a check*
• Letter from your bank listing your routing
and account numbers
* Do not use Deposit Tickets as they sometimes display
different numbers from the checking account.
Sign below to complete your enrollment for electronic fund transfer.
I have elected to have my payroll, stipends and expense funds deposited into the account(s) designated above and
have supplied the appropriate and correct information with which to set up the account(s).
Employee Name (please print)
Signature
Date
Please Note: There have been recent changes to the payment system rules for direct deposit of payroll. If you receive your payroll via
direct deposit at a bank located in the United States and then have the entire payroll amount forwarded to a bank in another country,
please advise the payroll department (or specific individual with your agency). There are new formatting requirements for these
transactions that the State of Nebraska needs to follow. It will not impact your payroll.
Rev: 20160404
Direct Deposit Enrollment Form
Name ________________________________ Address book # ______________ Agency # ______
(Please check one: Beginning new deposit ___ or changing existing information ___)
Pursuant to State of Nebraska Accounting policy (#41 & #42), payments for all wages. stipends and expense reimbursements will be
made by electronic funds transfer (EFT/Direct Deposit) to your choice of a financial institution or to a state authorized debit card.
You must enroll into the electronic funds transfer system if you are to receive any of these payments.
Payroll or Stipend Payment:
If you are an employee receiving wages or if you receive a stipend per your appointment, please complete
the table below with the appropriate direct deposit information.
If you are choosing the Focus Debit card option, complete the Focus Debit Card Sign-up Form; enter US
Bank in the Bank Name column and leave the account information blank.
Account Information
(S)aving or
Method
$ or %
(C)hecking
Code
Amount
Bank Name
Routing Number
Account Number
Method Codes: $ - Flat amount, % - percent of net pay deposited, R - Remainder of net for deposit
Expense Reimbursement Payment:
The following Expense Reimbursement information is separate from your payroll/stipend information and must be
completed to process the electronic transfer of your reimbursement.
Please complete the table below with the appropriate direct deposit information.
If you are choosing the Focus Debit card option, complete the Focus Debit Card Sign-up Form; enter US
Bank in the Bank Name column and leave the account information blank.
Account Information
(S)aving or
Method
(C)hecking
Code
Bank Name
Routing Number
Account Number
E
Attachments Required:
When providing new account information for direct
deposit, attach one of the following items for
verification:
• Blank check (voided)*
• Photocopy of a check*
• Letter from your bank listing your routing
and account numbers
* Do not use Deposit Tickets as they sometimes display
different numbers from the checking account.
Sign below to complete your enrollment for electronic fund transfer.
I have elected to have my payroll, stipends and expense funds deposited into the account(s) designated above and
have supplied the appropriate and correct information with which to set up the account(s).
Employee Name (please print)
Signature
Date
Please Note: There have been recent changes to the payment system rules for direct deposit of payroll. If you receive your payroll via
direct deposit at a bank located in the United States and then have the entire payroll amount forwarded to a bank in another country,
please advise the payroll department (or specific individual with your agency). There are new formatting requirements for these
transactions that the State of Nebraska needs to follow. It will not impact your payroll.
Rev: 20160404