TEXAS DEPARTMENT OF CRIMINAL JUSTICE EMPLOYEE PAYCARD AUTHORIZATION / CANCELLATION Section 1 EMPLOYEE IDENTIFICATION The following confidential information is used to ensure proper identification. Pursuant to requirements of law, including the USA PATRIOT Act, Bank of America is obtaining information (including name, address, date of birth and identification number) and will take necessary actions to verify your identity. Date of Birth Social Security Number (mmddyyyy) Employee Name Mailing address (PO Box not allowed) State Zip Code City Home Work Phone (area code and number) Country of Country of Other (specify) Other (specify) Residence citizenship Section 2 SETUP / CANCELLATION NEW ACCOUNT CANCELLATION Section 3 AUTHORIZATION FOR / CANCELLATION OF PAYCARD PARTICIPATION I authorize the Texas Comptroller of Public Accounts to deposit my payroll payments from the state of to my Bank of America Employee PayCard. I understand that the Texas Comptroller of Public Accounts will reverse any payments made to my account in error. I understand that deposits to the Employee PayCard are limited strictly to payroll payments from my employing state agency. I understand that the of fee structure for my Employee PayCard will remain in effect for 45 days once I terminate from state employment or notify my employing agency that I no longer wish to receive payroll payments through the Employee PayCard. After this time, the fees will be based on standard Bank of America pricing which will increase my fees when using the card. I understand that my employing agency will provide my personal information to the Bank of America on my behalf. I further understand that the Texas Comptroller of Public Accounts office will comply at all times with the National Automated Clearing House Association’s rules. (For further information on these rules, contact Bank of America.) Printed Signature Name Date Mail to: TDCJ Payroll Department, or FAX to: (936) 437-8644
TEXAS DEPARTMENT OF CRIMINAL JUSTICE EMPLOYEE PAYCARD AUTHORIZATION / CANCELLATION Section 1 EMPLOYEE IDENTIFICATION The following confidential information is used to ensure proper identification. Pursuant to requirements of law, including the USA PATRIOT Act, Bank of America is obtaining information (including name, address, date of birth and identification number) and will take necessary actions to verify your identity. Social Security Number Date of Birth (mmddyyyy) Employee Name Mailing address (PO Box not allowed) City State Zip Code Phone (area code and number) Home Work Country of Residence Other (specify) Country of citizenship Other (specify) Section 2 SETUP / CANCELLATION NEW ACCOUNT CANCELLATION Section 3 AUTHORIZATION FOR / CANCELLATION OF PAYCARD PARTICIPATION I authorize the Texas Comptroller of Public Accounts to deposit my payroll payments from the state of to my Bank of America Employee PayCard. I understand that the Texas Comptroller of Public Accounts will reverse any payments made to my account in error. I understand that deposits to the Employee PayCard are limited strictly to payroll payments from my employing state agency. I understand that the of fee structure for my Employee PayCard will remain in effect for 45 days once I terminate from state employment or notify my employing agency that I no longer wish to receive payroll payments through the Employee PayCard. After this time, the fees will be based on standard Bank of America pricing which will increase my fees when using the card. I understand that my employing agency will provide my personal information to the Bank of America on my behalf. I further understand that the Texas Comptroller of Public Accounts office will comply at all times with the National Automated Clearing House Association’s rules. (For further information on these rules, contact Bank of America.) Signature Printed Name Date Mail to: TDCJ Payroll Department, or FAX to: (936) 437-8644