Direct Deposit Form - University Of Michigan

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DIRECT DEPOSIT AUTHORIZATION
BA
Payroll Office – The University of Michigan
To have your paycheck or financial aid check direct deposited, complete the following information. ATTACH A BLANK, VOIDED
CHECK/DRAFT(s) to this form and return it to the Payroll Office, G395 Wolverine Tower-Low Rise, 3003 South State Street, SPC 1279, Ann
Arbor, MI 48109-1279. Fax: (734) 647-3983.
NOTE: This form must be in the Payroll Office 10 days prior to the pay date
SECTION I PERSONAL INFORMATION (Complete all information)
_____________________________________________________
_________________________
PRINT NAME – Last
First
Middle
UMID –REQUIRED FOR PROCESSING
____________________________________________________________________________________________________________
ADDRESS -
Number
Street
City
State
Zip
CAMPUS PHONE____________ HOME PHONE___________________________ EMAIL ADDRESS______________________
NOTE: You will not automatically receive a hardcopy, direct deposit stub. To view direct deposit stub detail, use the website
https://wolverineaccess.umich.edu
and follow the path for Employee Business (staff member) or Student Business (student) to the View Paycheck option. If you wish to receive a hardcopy, direct deposit stub,
complete the “Distribution of Direct Deposit Information” form on the Payroll web site at
SECTION II PURPOSE FOR PROCESSING FORM
(Check all that apply)
New Authorization____
Change Financial Institution(s) ____
Change Account _____ Reference Section III & Section IV
Cancel US Mail ____
Cancel direct deposit – campus distribution point will be__________________________ (choices below)
Plant
Dearborn
Payroll Woto -EQ-SQ-WQ-Markley- Athletics-Transport –Bldg Serv -Flint – Cashiers-LSA
SECTION III ACCOUNT DATA FOR ONE FINANCIAL INSTITUTION
;
;
;
-
New Account/Change Financial Institution
-
Cancel Account
- No Change
I choose to send my net pay to the following institution. I realize that this financial institution will be used for reimbursements through the
Procurement Systems.
Financial Institution
Account #
Type of account
Routing #
_______________________
_____________________
Checking*
Savings**
_________________________
* For checking/share draft accounts, YOU MUST ATTACH A BLANK, VOIDED CHECK/DRAFT
**For savings account, indicate Account # and Routing # (Obtain from your financial institution).
SECTION IV ACCOUNT DATA FOR PARTIAL DEPOSIT TO A SECOND FINANCIAL INSTITUTION
-
; -
;
;
;
- New Account/ Change Financial Institution
Cancel Account
Change Dollar Amount
- No Change
Financial Institution
Account #
Type of account
Routing #
_______________________
_____________________
Checking*
Savings**
_________________________
I choose to send a flat amount of my net pay $_________________per payday to the above financial institution with the remainder
going to the financial institution listed in Section III. Note: Flat amounts do not apply to weekly payrolls in which payroll
adjustments or financial aid payments are processed.
* For checking/share draft accounts, YOU MUST ATTACH A BLANK, VOIDED CHECK /DRAFT
**For savings account, indicate Account # and Routing # (Obtain from your financial institution).
SECTION V
I AUTHORIZE THE DEPOSIT OF MY PAYCHECK EACH PAYDAY TO THE INSTITUTIONS INDICATED
IN SECTIONS III & IV. I FURTHER AGREE TO THE FOLLOWING CONDITIONS:
1.
THIS AUTHORIZATION IS TO REMAIN IN FORCE UNTIL CANCELLED BY ME OR UNTIL ALL PAYROLL PAYMENTS ARE MADE
RESULTING FROM THE TERMINATION OF MY APPOINTMENT(s).
2.
The University reserves the right to recall or adjust any deposits improperly created and deposited to my account.
3.
I authorize the financial institution(s) to honor any recall/adjustment request made by the University, and I hereby absolve the financial institution(s)
from any liability that it might incur as a result of honoring such recall/adjustment request by the University. I further authorize the financial
institution(s) to withdraw monies available in any of my accounts at the institution in the event there are insufficient funds available, in the account
designated to receive deposits, to cover the deposit error at the time of the recall/adjustment.
4.
ANY CHANGE TO THIS AUTHORIZATION MUST BE RECEIVED BY THE PAYROLL OFFICE AT LEAST TEN DAYS PRIOR TO THE PAYDAY
IN WHICH THE UNIVERSITY IS OBLIGATED TO HONOR THIS AUTHORIZATION.
5.
I absolve the University from any liability to pay charges for insufficient fund transactions that result from a failure within the Automated Clearing House network
to correctly and timely deposit monies into my account.
Signature____________________________________________Date_______________
dirdep.doc,4/9/09

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