Payroll Direct Deposit Authorization Form

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T
ennessee Board of Regents
Payroll Direct Deposit Authorization Form 
Name 
 
ID or SSN # 
 
Address  
 
Phone No. (Home) 
 
(Work) 
 
 Email Address (for email notification of payroll remittance advice) 
 
 
 
 
1.    Net Pay Deposit: 
    
 
 
 
New
Change 
 
     Financial Institution Name: ________________________________________
Checking 
Savings 
Other
    Routing Transit No ________________________ Acct No   _______________________________________________ 
2.   Fixed Dollar Amount Deposit:     Amount $______________
New
Change 
Cancel 
     Financial Institution Name: ________________________________________
Checking 
Savings 
Other
    Routing Transit No ________________________ Acct No   ______________________________________________ 
 
3.   Fixed Dollar Amount Deposit:     Amount $______________
New
Change 
Cancel 
     Financial Institution Name: _______________________________________
Checking 
Savings 
Other
    Routing Transit No ________________________ Acct No   _____________________________________________ 
•
There may be up to sixty (60) days administrative processing before enrollment will become effective. 
•
It is your responsibility to notify Tennessee Board of Regents Payroll Office of any changes in your account, such as account closure 
or change in account number.   
•
This agreement may be cancelled by your financial institution or Tennessee Board of Regents. TBR reserves the right to 
automatically cancel your participation in the direct deposit program upon termination of employment. 
•
You must provide a blank voided check from your financial institution with the required information for direct deposit.  A deposit 
slip may not be acceptable documentation. Debit cards, prepaid credit cards, or PayPal accounts are not accepted. 
 
 
I authorize Tennessee Board of Regents to initiate credit entries to the account(s) indicated for the purpose of depositing 
earnings from my employment.   
 
 
 
Signature ____________________________________________________________      Date __________________________ 
REV: 09/09

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