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AC 2772 Rev. 11/12 PLEASE SEE REVERSE SIDE FOR INSTRUCTIONS Direct Deposit Form for NYS Employees To be used for enrollment changes and cancellations Section A Employee Information NAME LAST FIRST MI WORK PHONE N NYS EMPLID AGENCY/DEPT CODE For more than three accounts or if you prefer to list each Financial Institution on a separate form use additional forms as necessary. See instructions below for Section C. Section A Indicate your name work.

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