Texas direct deposit authorization form 2025

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Earnings - Pay stubs or copy of checks dated within sixty days from the date you submit your application or renewal application, a statement from employer that includes their name, address and phone number or self-employment records.
A direct debit form is an application form that you must fill in which provides your details. This confirms that you give permission for your account to be debited.
Form 5871-S is completed and submitted as a condition of approval or renewal of a Texas Medicaid enrollment application or a contract agreement between the disclosing entity (applicant/provider) and HHSC for any services program. A full and accurate disclosure of ownership and control interest is required.
This form is used by vendors, employees and individual recipients to: Receive payments from the state of Texas by direct deposit. Change or cancel existing direct deposit information.
I hereby voluntarily authorize the Company named above (hereafter Employer), either directly or through its payroll service provider, to deposit any amounts owed me, by initiating credit entries to my account (s) at the financial institution (s) of my choice (hereinafter Bank) indicated on this form.
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Direct Deposit Authorization Form (74-176) This form is used by vendors, employees and individual recipients to: Receive payments from the state of Texas by direct deposit. Change or cancel existing direct deposit information.

form 74 176