"Reversal or Return of Direct Deposit Request" - Ohio

Reversal or Return of Direct Deposit Request is a legal document that was released by the Ohio Department of Administrative Services - a government authority operating within Ohio.

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  • Released on June 1, 2015;
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REVERSAL or RETURN of DIRECT DEPOSIT REQUEST
EMPLOYEE DATA: 
NAME _____________________________________________________   EMPL ID# ___________________________ 
Full Time ____________               Part Time ______________             Temporary ______________ 
Agency Name & Number ______________________________  PPE  _____________   Payday   ______________ 
REASON FOR REQUEST:  ________________________________________________________________________  
 
PREVENT DIRECT DEPOSIT ________  REVERSE DIRECT DEPOSIT ________ RETURNED BY BANK ______________ 
             
 
EFT RECORD HAS BEEN                       CORRECTED  ________              CANCELLED    __________ 
ACCOUNT INFORMATION (at time of Deposit)
CHECKING ____________ SAVINGS _____________
TRANSIT ROUTING NUMBER ___________________________
ACCOUNT NUMBER _______________________________
WARRANT NUMBER __________________________ AMOUNT DEPOSITED/RETURNED _____________________________
WAS THERE AN ATTACHMENT? YES ________ NO __________
AMOUNT ____________________________
OVERPAID (NO PAY DUE)
_____________________________
OVERPAID (PAY DUE ONLY):     FILL OUT PAGE TWO 
Deductions that need to be taken on check written for an overpayment: _____________________________________________ 
SIGNATURE: 
Agency Approval ___________________________________ Date __________________________ Time ______________________ 
Telephone ______________________________________ Ext _________________ Fax # __________________________________ 
 
  Date: ______________________ 
  Prepared by: ________________ Gross: __________________ Net: __________________ Check # ________________ Stock # _______________________  
  
  I ACKNOWLEDGE RECEIPT OF A CHECK WITH THE ABOVE NUMBER, DATE AND PAYEE 
  SIGN HERE ____________________________________________________    DATE _____________________________________________ 
 FAX APPROVED FORM TO: DAS HRD PAYROLL SERVICES @ 614.466.1565 
  
 NOTE: Form will only be processed if it is approved by an authorized agency central office employee 
Revised 06‐01‐2015 
REVERSAL or RETURN of DIRECT DEPOSIT REQUEST
EMPLOYEE DATA: 
NAME _____________________________________________________   EMPL ID# ___________________________ 
Full Time ____________               Part Time ______________             Temporary ______________ 
Agency Name & Number ______________________________  PPE  _____________   Payday   ______________ 
REASON FOR REQUEST:  ________________________________________________________________________  
 
PREVENT DIRECT DEPOSIT ________  REVERSE DIRECT DEPOSIT ________ RETURNED BY BANK ______________ 
             
 
EFT RECORD HAS BEEN                       CORRECTED  ________              CANCELLED    __________ 
ACCOUNT INFORMATION (at time of Deposit)
CHECKING ____________ SAVINGS _____________
TRANSIT ROUTING NUMBER ___________________________
ACCOUNT NUMBER _______________________________
WARRANT NUMBER __________________________ AMOUNT DEPOSITED/RETURNED _____________________________
WAS THERE AN ATTACHMENT? YES ________ NO __________
AMOUNT ____________________________
OVERPAID (NO PAY DUE)
_____________________________
OVERPAID (PAY DUE ONLY):     FILL OUT PAGE TWO 
Deductions that need to be taken on check written for an overpayment: _____________________________________________ 
SIGNATURE: 
Agency Approval ___________________________________ Date __________________________ Time ______________________ 
Telephone ______________________________________ Ext _________________ Fax # __________________________________ 
 
  Date: ______________________ 
  Prepared by: ________________ Gross: __________________ Net: __________________ Check # ________________ Stock # _______________________  
  
  I ACKNOWLEDGE RECEIPT OF A CHECK WITH THE ABOVE NUMBER, DATE AND PAYEE 
  SIGN HERE ____________________________________________________    DATE _____________________________________________ 
 FAX APPROVED FORM TO: DAS HRD PAYROLL SERVICES @ 614.466.1565 
  
 NOTE: Form will only be processed if it is approved by an authorized agency central office employee 
Revised 06‐01‐2015 
PAGE TWO FOR REVERSAL or RETURN OF DIRECT DEPOSIT REQUEST
Key EC = Earnings Code D/H=Dollars/Hours
Name_____________________________________________________ EMPLID ________________ AGENCY ____________________
If manual for Additional pay or $ earnings - E C ________________ D/H___________
If re-write - EC _________ D/H_________ EC ________ D/H ________ EC ________ D/H ________
EC ________ D/H ________ EC ________ D/H ________ EC ________ D/H ________
S
M
T
W
TH
F
S
S
M
T
W
TH
F
S
S
M
T
W
TH
F
S
EACH SET OF BLOCKS REPRESENTS A PAY PERIOD TIME FRAME. IF THE REQUEST IS FOR MORE THAN ONE PAY
PERIOD, PLEASE ENSURE YOU FILL IN EACH PAY PERIOD SEPARATELY.
FILL IN THE DATES WITH THE CORRECT CORRESPONDING DAY IN THE PAY PERIOD FOR THE MANUAL
REQUESTED.
REMEMBER TO USE THE APPROPRIATE TRC CODE.
PAYDAY WEEKS-PLEASE ENTER TIME IN OAKS TIMESHEET.
PAY PROCESSING WEEKS-DO NOT ENTER THE TIME IN THE OAKS TIMESHEET (THIS WILL DELAY THE
PROCESSING OF THE MANUAL)
REMEMBER TO ENTER A COMMENT IN THE BUBBLE ON THE OAKS TIMESHEET-(DAS/HRD PAYROLL WILL ENTER
COMMENT AND TIME FOR REQUESTS ON PAY PROCESSING WEEK)
FOR APPROVING AGENCIES, DAS/HRD PAYROLL WILL APPROVE THE PAYABLE TIME WITH THE AUTHOR
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