Independent Contractor (Ic) Checklist (Page 8 of 10) in pdf

This form needs to be filled out and submitted one time only

Submit original form only. Faxes, copies or emails will not be processed

This form should be printed out, completed off-line, and returned to CSUSM Accounts Payable, Craven 4600

Independent Contractor

Direct Deposit Authorization

This form may NOT be used to request Payroll direct deposit.

It is intended to be used for Independent Contractor payments only.

CHECK ONE:

New Request

Change of Bank or Account Number

Delete Authorization

Name:

PeopleSoft Vendor ID

Last, First

To be completed by Accounts Payable

Bank Name:

Bank Address:

Bank Routing Number:

Please verify your routing number with your financial institution.

Checking

Savings

Account Number:

I hereby authorize in accordance with the rules and regulations of the National Automated Clearinghouse Association

("NACHA") California State University San Marcos ("CSUSM"), to credit any reimbursements due to me via

automated clearinghouse electronic fund transfer ("ACH") to the bank and bank account owned by me referenced above.

Further, I hereby authorize CSUSM to withdraw funds from the above referenced bank account owned by me via ACH

debit. Such debits are authorized only to perform legitimate and appropriate financial transactions between me and

CSUSM including, but not limited to, retrieval of reimbursement overpayments. This authorization will remain in effect until

cancelled in writing. A new authorization must be completed if I change my bank account, close my bank account, or change

financial institutions.

Note: I understand that California State University San Marcos (CSUSM) requires ten (10) business days to set up this

initial authorization and two (2) business days for funds to become available following an ACH electronic funds transfer.

Signature:

Date:

Required

Phone Number:

(

)

E-Mail:

Recipient's address

Privacy Notification

The State of California Information Practices of 1977 (effective July 1, 1978) requires the University to provide the following information to individuals

who are asked to supply information about themselves. The principal purpose for requesting information on this form is to acquire authorization for

reimbursement distribution to a financial institution of the individual's choosing. Furnishing all information on this form is mandatory. Failure to provide

such information will delay or may even prevent completion of the action for which the form is being submitted.

*TAPE A PRE-PRINTED, VOIDED CHECK HERE*

IF THE ADDRESS ON YOUR CHECK IS INCORRECT, PLEASE LINE OUT AND WRITE IN CURRENT ADDRESS

DIRECT DEPOSIT CANNOT BE PROCESSED WITHOUT A VOIDED CHECK

Submit this orginal form to CSUSM Accounts Payable, Craven 4600

Attach a personalized deposit slip if you are using a savings account

Please return completed form to CSUSM Attn: Becky Henwood, Accounts Payable, Craven 4600-29

333 S. Twin Oaks Valley Road, San Marcos, CA 92096-0001

Contact Becky Henwood at (760) 750-4442 or bhenwood@csusm.edu for any questions

No faxes, copies or emails please. Allow two weeks for processing

Revision Date: 04/15/13