Authorization Agreement For Employee Direct Payroll Deposits Form
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1University of Massachusetts
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AUTHORIZATION AGREEMENT FOR EMPLOYEE DIRECT PAYROLL DEPOSITS
Employee Name: _________________________
Effective Date: ______________
Employee ID: ____________________________
Phone: ___________________
BANK INFORMATION
(Select Balance on Only One Box)
Deposit Priority (1) – Deducts this amount 1st
Allow Partial Deduction
Full Deposit or Balance
New
Delete
Change New Amount $ ____________
Bank Transit/Routing# (9 digits): ____________________ Account Number: _____________________
Bank Name: ___________________________________
Checking
Savings
Deposit Priority (2) – Deducts this amount 2nd
Allow Partial Deduction
Full Deposit or Balance
New
Delete
Change New Amount $ ____________
Bank Transit/Routing # (9 digits): ____________________ Account Number: _____________________
Bank Name: ___________________________________
Checking
Savings
Deposit Priority (3) – Deducts this amount 3rd
Allow Partial Deduction
Full Deposit or Balance
New
Delete
Change New Amount $ ____________
Bank Transit/Routing # (9 digits): ____________________ Account Number: ______________________
Bank Name: ___________________________________
Checking
Savings
Deposit Priority (4) – Deducts this amount 4th
Allow Partial Deduction
Full Deposit or Balance
New
Delete
Change New Amount $ _____________
Bank Transit/Routing # (9 digits): ____________________ Account Number: ____________________
Bank Name: ___________________________________
Checking
Savings
I herby authorize the University of Massachusetts to deposit my net pay as indicated above at the financial institution(s) named above. I
understand the University of Massachusetts may cause my account to be adjusted to the extent necessary to correct any over deposit and I agree to
hold the above named financial institution(s) harmless for any erroneous deposits or adjustments not caused by the financial institution.
It is understood that I may terminate this agreement at any time by written notification to the University of Massachusetts. Any such notification
to the University of Massachusetts shall be effective only with respect to entries initiated by the University after receipt of such notification and
reasonable opportunity to act upon it. Any such notification to the bank by the employee is unacceptable. The bank may terminate this agreement
by written notice to the employee for just cause.
EMPLOYEE SIGNATURE: ____________________________________________ DATE: ______________________
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Parent category: Business