Direct Deposit Hardship Exemption Request Form printable pdf download

University of Arkansas for Medical Sciences

Direct Deposit Hardship Exemption Request

Section I

Name________________________________________________________________________________

Position Title__________________________________ SAP #___________________Mail Slot_________

Department___________________________________Phone_____________E-mail_________________

Section II

In accordance with Act 1887 of 2005, as a condition of employment, a person hired or appointed to a position in any

agency/institution in State government on or after August 12, 2005 shall be required to accept payment or wages by

electronic warrants transfer (ACH). The ACH payment shall be in the form of a direct deposit.

____ (initial) I understand that as a condition of employment, because I am a new hire or rehire applicant, I must comply

with the law and enroll and remain enrolled in direct deposit or request an exemption from these requirements. I

understand that I can go no further in the hiring process until the request for exemption is reviewed.

_____ (initial) I am a current employee (hired before March 22, 2005) requesting discontinuation of direct deposit due

to hardship. I understand that should I be granted my request, I will be charged a one-time $50.00 fee payable to UAMS

and submitted to the UAMS Treasurer’s Office located on the 1

floor of the Central Hospital Building Room M1092. If

the exemption is approved it will not be processed until the $50.00 fee has been submitted and processed by the

Treasurer’s Office.

Section III

I hereby request an exemption from the requirement s of mandatory participation in direct deposit for the following

hardship:

Section IV

_____ (initial) I understand that if the exemption is approved and if I re-enroll in direct deposit at a later date that I

cannot request a second exemption at any time.

Employee Signature______________________________________________ Date__________________

To be completed by the Office of Human Resources and Treasury Department if necessary:

_____Request Approved

____Request Denied

Section V

Signature______________________________________________________ Date__________________

UAMS Associate Vice Chancellor, Chief Human Resources Officer or Designee

If approved, $50 payment has been paid: _______ yes ________ no

Signature______________________________________________________ Date__________________

Treasury Office Representative

Employee - fax completed form to the Office of Human Resources 501-686-5386 or slot 566.

Human Resources send copy to Treasury slot 560 and employee’s slot listed above.

Final copy faxed to OHR Records 501-603-1318 or slot 564-1.

Direct Deposit Hardship Exemption Request Form