Direct Deposit Authorization Agreement Form printable pdf download

Direct Deposit

Authorization Agreement

PLEASE TYPE OR PRINT

Employee Name

Seminole State College ID

Phone Number

I would like to:

START a new direct deposit (you can have up to three see Note 1 below)

CHANGE an existing direct deposit (see Note 2 below)

CANCEL an existing direct deposit (allow one full pay period before closing your bank account)

Priority #1 (check one)

Checking Account

Savings Account

Amount**__________________

Account Number ____________________________________________________

ABA Num. _________________

Financial Institution Name _________________________________________________________________________________

Priority #2 (check one)

Checking Account

Savings Account

Amount**__________________

Account Number ____________________________________________________

ABA Num. _________________

Financial Institution Name _________________________________________________________________________________

Priority #3 (check one)

Checking Account

Savings Account

Amount**__________________

Account Number ____________________________________________________

ABA Num. _________________

Financial Institution Name _________________________________________________________________________________

**Enter “Balance” in the amount field, if you want the Net Pay amount of your check deposited into this account. Enter the “Dollar Amount”

in the amount field if you want part of your pay to be deposited into another account. It is required to have one account designated as

“Balance”. Accounts Payable will direct deposit your expense reimbursements (ie; travel, tuition, professional study and miscellaneous) to the

“Balance” account.

I hereby authorize and request Seminole State College (Tax ID Number:59-1210158) to initiate credit entries, if necessary, debit entries

and adjustments for any credit entries in error, to my account at the financial institution named. This authorization is to remain in effect

until withdrawn by me in writing with sufficient notice to Seminole State College to allow adequate time to effect termination of the

direct deposit. This includes my agreement to pay bank services fees for a rejected direct deposit to my account which results from my

failure to notify Seminole State College, in a timely manner, that the account indicated above has been closed.

Signature

Date

Note 1: For a new direct deposit, it may take up to two pay periods for the direct deposit to process to your account. A check will be

issued for the first pay period and possibly the second pay period.

Note 2: When you make a change to your account number or your ABA (routing #), your net pay may be a check on the pay period

following the change. The second net pay you receive after making the change will be direct deposited.

ATTACH YOUR VOIDED CHECK BELOW

906

SAMPLE

__________ 20_____

63-215

632

PAY TO THE

Return completed form to:

ORDER OF ________________________________________________ $__________

Payroll Services

Dollars

_______________________________________________________________________

Room L213E

100 Weldon Boulevard

Sanford, FL 32773

FOR __________________________

_________________________________

: ABA NUMBER

: ACCOUNT NUMBER

227886 11-16-11

Direct Deposit Authorization Agreement Form

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