Direct Deposit Authorization Form printable pdf download

Return to: Student Payroll

Waller Administration Bldg.

STATE SYSTEM of HIGHER EDUCATION

DIRECT DEPOSIT AUTHORIZATION

Name ___________________ Social Security OR Personnel Number _________

Email address (Please Print)___________________________

I hereby authorize the Pennsylvania State System of Higher Education to (check one)

START ___________

STOP ___________

CHANGE __________

I hereby decline direct deposit_______ (Complete section 2 below)

Total bi weekly payroll deduction to the Financial Institution shown below. You may designate any bank, savings

and loan association, or credit union in the U.S. that (1) is a member of the Federal Reserve System and (2)

accepts electronic funds transfer. Payroll will notify you if the institution you choose does not qualify.

Financial Institution’s Name _______________________________

Transit Routing Number __________________________________

Account Number ________________________________________

Type of Account (Checking or Savings) ________________________

Deduction Amount (Dollar Amount or Net) _____________________

Effective with pay date of __________________________________

I have an established account at the Financial Institution indicated above, and authorize the State System of

Higher Education to initiate credit entries and to initiate debit entries and adjustments for any credit entries

in error to my (our) account (s) indicated above. I have provided a copy of a voided check or a deposit slip (see

attached) solely for the purpose of verifying my account number and the Financial Institution’s routing number.

My authorization will remain in effect until revoked by me in writing or I terminate my employment with the

State System of Higher Education.

Signature _____________________________

Date___________

Section 2-Declining Direct Deposit-

By declining direct deposit of my pay, I will be required to pick up my paycheck in the

Student Payroll Office, 2

Floor, Waller Administration Bldg, each biweekly payday

between 9:00am to 11:30am.

If I have not picked up my check by 11:30am, the check

will be mailed to

the address stated on my check. CHECKS CAN ONLY BE

DISTRIBUTED ON PAY DAY

Signature _____________________________

Date___________

Direct Deposit Authorization Form