Direct Deposit Authorization Faculty/staff Form printable pdf download

STATE SYSTEM of HIGHER EDUCATION

DIRECT DEPOSIT AUTHORIZATION

FACULTY/STAFF

Name _______________________________ Personnel Number _________

I hereby authorize the State System of Higher Education to (check all applicable)

PAYROLL

TRAVEL REIMBURSEMENT

START

_______

STOP

_______

CHANGE

_______

Total bi-weekly payroll deduction and (or) travel reimbursement 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.

-Direct Deposit Distribution

Financial Institution’s Name _______________________________

Transit Routing Number __________________________________

Account Number ________________________________________

Type of Account - Checking or Savings (please circle one)

Deduction Amount (Choose one) ______ Net Pay or Specified Amount $_____________

2nd-Direct Deposit Distribution

Financial Institution’s Name _______________________________

Transit Routing Number __________________________________

Account Number ________________________________________

Type of Account - Checking or Savings (please circle one)

Deduction Amount (Choose one) ______ Net Pay or Specified Amount $_____________

Effective with pay date of

__________________________________

***Multiple distributions are available. Please fill out additional forms.

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. 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_________

Co-Signature if Joint Account (optional)

______________________

Payroll Office Use Only: Notified AP Office of start, stop, change

Date_______________

Direct Deposit Authorization Faculty/staff Form