Authorization For Direct Deposit Of Payroll Form

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University of Wisconsin Service Center

Human Resource System

Authorization for Direct Deposit of Payroll

The University of Wisconsin System distributes pay using an electronic direct deposit program.

mm/dd/yyyy

Select One:

Biweekly Payroll (Classified/LTE/Student/Unclassified Hourly appointments)

Effective Date:

As Soon As Possible

Monthly Payroll (Faculty, Academic Staff, Teaching and Research Assistant appointments)

Future Pay Date: ______________

Employee Information | You are highly encouraged to complete this form online, print, and sign it; or please print legibly to prevent delays.

Payroll Empl ID OR

Name (Last, First, MI): _____________________________________________________

Social Security Number (Last 4 Digits Only): ________________________

Phone Number: ______________________________________

Email Address: __________________________________________________________________

Primary Account |

This is where your entire paycheck or the balance is deposited after the % or $ amount is deducted from the second and third accounts listed below.

Select one:

Account Type

ABA Transit Routing Number:

(Select one):

Start

Checking

Account Number: ______________________________________________________________

Change

NET PAY

Savings

No Change

Name of Financial Institution: _____________________________________________________

Financial Institution City, State: ___________________________________________________

Second Account | Optional

% OR $ OF NET

DISTRIBUTION

Select one:

Account Type

ABA Transit Routing Number:

(Select one):

Start

Checking

Account Number: ______________________________________________________________

Change

Savings

Name of Financial Institution: _____________________________________________________

Cancel

No Change

Financial Institution City, State: ___________________________________________________

Third Account | Optional

% OR $ OF NET

DISTRIBUTION

Select one:

Account Type

ABA Transit Routing Number:

(Select one):

Start

Checking

Account Number: ______________________________________________________________

Change

Savings

Name of Financial Institution: _____________________________________________________

Cancel

No Change

Financial Institution City, State: ___________________________________________________

Check this box if the entire amount of your direct deposit is ultimately deposited to a financial institution outside of the United States.

Read statement carefully: I authorize the University of Wisconsin to direct deposit funds to my account in the financial institution listed above. If funds to which I am

not entitled are deposited in my account, I authorize the University to initiate a correcting (debit) entry. I understand that the authorization may be rejected or

discontinued by the University at any time (see back for details). If any of the above information changes, I will promptly complete a new authorization agreement.

If the direct deposit is not stopped before closing an account, funds payable to you will be returned to the University for distribution. This will delay your check.

Employee Signature: _______________________________________________________________________ Date: ___________________________ (mm/dd/yyyy)

P100.20150817

Additional information is on the reverse side.