Direct Deposit Form - Employee Authorization Agreement - Indianapolis Public Schools -
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Indianapolis Public Schools
________________________________________
Employee Authorization Agreement
Direct Deposit
Form DDP: 11-02-2010
SOCIAL SECURITY NUMBER_______________________________________________________________________________
EMPLOYEE ID NUMBER___________________________________________________________________________________
Printed Name: ___________________________________________________________
Signature: ____________________________________________________________
Street Address, City, State, Zip Code: ________________________________________________________________________________________________________________
I authorize you and the financial institution(s) listed below to initiate electronic credit entries, and if necessary, debit entries and adjustments
for any credit entries in error to my accounts.
_______ New or Change (provide all info again as though new).
YES - PRE-NOTE (Pre-Noting takes 2 Pays)
We pre-note to verify that your new or changed direct deposit information will correctly transfer
_______ Stop Authorization (all accounts will be stopped).
your funds to your account(s) using normal ACH processing channels. During pre-notification,
you receive a"LIVE" payroll check that needs to be physically taken to your financial institution.
_______ PNC BANK Stored-Value Debit Card (SVDC).
NO - DO NOT PRE-NOTE
Your new or changed direct deposit information will take effect without transfer verification.
"C" = Checking
Bank Name
City/State
"S" = Savings
* Take Home Pay
Account Number
ABA Routing Number
Line 1
Do NOT enter Amount
Want fixed amounts?
If yes, complete lines 2, 3 and/or 4.
"C" = Checking
Amount to be
Bank Name
City/State
"S" = Savings
Deducted Each Pay
Account Number
ABA Routing Number
Line 2
Line 3
Line 4
* Take Home Pay = gross pay minus all deductions ( e.g., taxes, medical, union dues, etc. ) you have authorized on Lines 2, 3 or 4 above.
FAX to : 317-226-3437 (1) completed form (2) voided check ( deposit slips are NOT accepted for checking accounts )
OR
MAIL to: Payroll Office · JMFCES · Room B06 · 120 E. Walnut Street · Indianapolis, IN 46204-1312
Please Note: 1) In the event that the system is unable to make the split between lines 1 through 4 as requested, YOUR UNSPLIT BALANCE WILL BE AUTOMATICALLY DEPOSITED
IN THE BANK ACCOUNT DESIGNATED ON Line 1;
2) YES - PRE-NOTE is the default pre-notification option. If you do not check a pre-notification option, YOUR NEW OR CHANGED DIRECT DEPOSIT INFORMATION
WILL BE PRE-NOTED.
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