Payroll Form Active Employee - Direct Deposit Authorization

PR-01-001 Effective: April 8, 2020

INSTRUCTIONS: Email any questions to Finance.Payroll@montgomerycountymd.gov or call the Payroll Section at (240) 777-8840

Use this form to initiate direct deposit of your pay and any reimbursements.
Allow 30 days to become effective. DO NOT CLOSE EXISTING BANK ACCOUNTS UNTIL FIRST DEPOSIT IS RECEIVED IN THE NEW ACCOUNT.
Please upload within this form, a copy of your county ID or driver's license

Employee Name

Phone Number

Employee ID

Last 4 of Social Security

Please include a copy of your ID. You may also submit a voided check.

Click Here to Upload

Is this a new authorization or a change (Net Pay Account)

New

Change

NO CHANGE

Bank Details

Is this a checking or savings account?

Checking

Savings

Account Number

ABA Routing Number

Name of Financial Institution

Optional Flat Amount Deposit (to 2nd Account)

Is this a New Authorization or a change? (2nd Account)

New

Change

NO CHANGE

Flat Amount Deposit Each Pay Period (to 2nd Account)

You may also submit a voided check. (2nd Account)

Click Here to Upload

Bank Details (2nd Account)

Is this a checking or savings account? (2nd Account)

Checking

Savings

Account Number

ABA Routing Number

Name of Financial Institution (2nd Account)

Optional Flat Amount Deposit (to 3rd Account)

Is this a New Authorization or a change? (3rd Account)

New

Change

NO CHANGE

Flat Amount Deposit Each Pay Period (to 3rd Account)

You may also submit a voided check. (3rd Account)

Click Here to Upload

Bank Details (3rd Account)

Is this a checking or savings account? (3rd Account)

Checking

Savings

Account Number

ABA Routing Number

Name of Financial Institution (3rd Account)

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Employee Signature

First Name

Last Name

Choose how to sign

Draw Type

I certify that the above account(s) are located in the U.S., bear my name and that I am an unrestricted and authorized signor on each account. I authorize Montgomery County Government (MCG) and the bank(s) indicated above to deposit the assigned amount of my pay and any reimbursements automatically into my savings or checking account(s) each payday. If money to which I am not entitled is deposited into my account, I understand that MCG has the authority to direct the bank(s) to return those funds. I have read the information contained in this form and my signature confirms my understanding.

PAYROLL OFFICE USE ONLY:
Processed by ____________________________________

Effective Date: _________________