Download payroll direct deposit request

CITY OF BALTIMORE
INSTRUCTIONS:
PAYROLL DIRECT DEPOSIT REQUEST
1. Print Legibly in ink. 2. Refer to your pay stub for department, location code, & employee ID. 3. Forward to Central Payroll.
Social Security Number
Employee ID Nbr
Last Name
First Name
MI
Dept/Loc
I authorize the Central Payroll Division to take the following action with my net pay:
(Check Appropriate Box)
Account #
Enter Name of Financial Institution:
Begin / New Direct Deposit To:
PAY CARD PILOT
Attach voided check for starting new
Checking
Discontinue Direct Deposit To:
Routing Number ______________________________________
Account Number ______________________________________
By signing this form, I am authorizing YouthWorks and Baltimore City Government Central Payroll Division to
enroll me in Direct Deposit, so that I can use the YouthWorks PayCard that is personalized to me.
In the event that the Central Payroll Division deposits funds to which I am not entitled to, funds that were deposited
to my account in error, I hereby authorize and direct the financial institution to return said funds to the Central
Payroll Division as soon as possible.
Parent Signature (if youth is under 18 years old)
Central Payroll Division Use Only
Employee Signature
Account #
Date
Daytime Phone No.
When filling out this form, please only fill out the sections in the green boxes: Social Security Number, Last Name, First Name, MI,
Employee Signature, and Parent Signature (if under 18).
This form is required of all YouthWorkers, because we are transitioning from paper checks to debit PayCards. These debit cards
are free to the YouthWorkers. Please do not write the account or routing number of your personal bank account in the boxes
above, as we will not be allowing youth to directly deposit their paychecks into their own bank accounts for the 2017 YouthWorks
year. If you have any questions about the debit PayCards for YouthWorks 2017, please refer to the PayCard Q&A document in the
Documents section of the YW website located at: https://goo.gl/jnnjDe