NEW ENROLLMENT. PERSON (S) NAMED ON THE ACCOUNT (print exactly as it appears on your check) ACCOUNT TYPE SAVINGS OR CHECKING (Circle only One) *ABA NUMBER ACCOUNT NUMBER *Please confirm with your financial institutions that the ABA No. and account type is correct for Direct Deposit. Please attach a voided personal check or a copy of a personal check. COPY OF SAMPLE CHECK ATTACHED
NEW ENROLLMENT. Check here if you have never participated in UK’s voluntary retirement plan before. If you do not have an existing account with the company(ies) selected, an application form for each company selected must accompany this authorization.
NEW ENROLLMENT. Select New Enrollment to enroll as an employer in the eGarnishment Program and allow FTB to serve Earnings Withholding Orders for Taxes (EWOTs), Earnings Withholding Orders (EWOs), delays, modifications, terminations, and any other notice or document to be provided (collectively, “eGarnishments”) to the employer or the payroll service provider (PSP) by electronic transmission. This completed and signed enrollment form serves as the official data processing document with us. Terminate Enrollment Select Terminate Enrollment to end the employer’s participation in the eGarnishment Program and receive paper garnishments. Selecting this option will end electronic delivery of garnishments to the current PSP. To change your participation, e.g., have garnishments electronically delivered to the employer directly or to change PSPs, re-enroll by selecting New Enrollment. Refer to FTB 1052, Electronic Wage Garnishment Program Participation Guide, for additional information. Refer to How to Get Forms. In this document. we refer the federal employer identification number as FEIN and the state employer identification number as SEIN. Check the appropriate box and complete the listed sections. ◻ New Enrollment (Complete Part 1, and Part 2 if applicable.) ◻ Terminate Enrollment (Complete Part 1, and Part 2 if applicable.) Part 1: Employer Information Legal name of employer XXXX Trade name of business (doing business as, if different from legal name) SEIN Street address (number and street) or PO box Apt. no./ste. no. City State ZIP Code Foreign address Employer Contact Information Primary contact’s first and last name Phone Email Secondary contact’s first and last name Phone Email Part 2: Authorization for FTB to Send eGarnishments to Your Payroll Service Provider – Optional The employer can authorize FTB to electronically send eGarnishments to their PSP in lieu of their employer. If during the employer’s participation in the eGarnishment Program with a PSP, the PSP notifies FTB that they will no longer process eGarnishments for the employer, the employer’s participation will be deemed terminated. The employer will need to submit a new enrollment form to receive eGarnishments or to have a new PSP receive eGarnishments on their behalf. Payroll service provider’s name Street address (number and street) or PO box Apt. no./ste. no. City State ZIP Code Payroll Service Provider Contact Information Primary contact’s first and last name Phone Email Secondary contact’s first and last...
NEW ENROLLMENT. PERSON (S) NAMED ON THE ACCOUNT (print exactly as it appears on your check) ACCOUNT TYPE SAVINGS OR CHECKING (Circle only One) *ABA NUMBER ACCOUNT NUMBER *Please confirm with your financial institutions that the ABA No. and account type is correct for Direct Deposit. Please attach a Voided personal check or a copy of a personal check. COPY OF SAMPLE CHECK ATTACHED EMPLOYEE AUTHORIZATION: By signing below, I hereby authorize my employer, Montefiore Medical Center (“ Montefiore”) to deposit my net pay directly into my checking or savings account each payday. If any monies to which I am not entitled are deposited into my account for any reason, including as the result of Montefiore’s error I authorize Montefiore to direct the bank to return such funds directly to Montefiore in the full amount of the improper payment. This authorization allows Montefiore to direct my bank to return the funds at the time the overpayment is discovered, regardless of when the funds were improperly deposited into my account. I agree that this authorization will remain in effect until I provide my employer with written cancellation to terminate this service. I understand that 4 weeks must be allowed for implementation and any changes in direct deposit. SIGNATURE DATE
NEW ENROLLMENT. Check here if you have never participated in the University’s 457(b) voluntary account with the company(ies) selected. An application form for each company selected must accompany this authorization.
NEW ENROLLMENT
