Direct Deposit Authorization Form printable pdf download

BALL STATE UNIVERSITY PAYROLL & EMPLOYEE BENEFITS

Authorization for Direct Deposit

Instructions:

1. Contact Treasury Direct to establish an account.

2. Once you have a valid TreasuryDirect account number, fill in the form. Note account number

maybe alpha‐numeric.

3. Print the completed form, sign and mail to BALL STATE UNIVERSITY,

PAYROLL DEPARTMENT (Administration Bldg 029) 2000 W. University Ave Muncie, IN 47306

BSU ID: _000‐______________________

Last Name: _______________________ First Name: ____________________ M.I. _________

START

STOP

CHANGE

direct deposit

my current Treasury Direct

to my Treasury Direct

authorization amount or account number.

account

Financial Institution: ____________TREASURYDIRECT ____________________________

051736158

ABA (Routing) Number: _________

_______________________________

Your TreasuryDirect Account Number: __________________________________________

Amount $ _______________________________________

I hereby authorize Ball State University to deposit automatically to my account at TreasuryDirect as I have indicated above. I understand that the

very earliest I can expect my account to be credited will be on payday. I further understand that if I change or terminate my account(s) without

notifying Ball State payroll in writing my deduction may be delayed.

Signature: _________________________________________

Date: _____________________________

BSU Email: _________________________________________

Phone Number: _____________________

PEB Notes:

Received in PEB Office (date stamped)

Confirm: 610 code is not active ___________

Setup Code 965‐000‐000 (Action Code: 102)

Coverage Date: ______________________________

Deduction Amount: ___________________________

Setup Screen 035 by: __________________________

On Date: _____________________________________

Verified by: __________________________________________

On Date: _____________________________________

Direct Deposit Authorization Form