University of Southern Indiana



0-444500 University of Southern IndianaPayroll Direct Deposit Authorization-68580-2540Please PrintEmployee Name: ________________________________________Employee ID #: ______________ Last First MI00Please PrintEmployee Name: ________________________________________Employee ID #: ______________ Last First MI FORMCHECKBOX Direct Deposit #15645785508000043484805080000-68580-3810Financial Institution _______________________________Checking Savings Account Number____________________ Amount Deposited $____________ OR Percent % ____________00Financial Institution _______________________________Checking Savings Account Number____________________ Amount Deposited $____________ OR Percent % ____________-68580182880Financial Institution _______________________________Checking Savings Account Number____________________ Amount Deposited $____________ OR Percent % ____________00Financial Institution _______________________________Checking Savings Account Number____________________ Amount Deposited $____________ OR Percent % ____________Direct Deposit #2-68580165100Financial Institution _______________________________Checking Savings Account Number____________________ Amount Deposited $____________ OR Percent % ____________00Financial Institution _______________________________Checking Savings Account Number____________________ Amount Deposited $____________ OR Percent % ____________Direct Deposit #3Direct Deposit #4-6858023495Financial Institution _______________________________Checking Savings Account Number____________________ Amount Deposited $____________ OR Percent % ____________00Financial Institution _______________________________Checking Savings Account Number____________________ Amount Deposited $____________ OR Percent % ____________Cancel direct deposit __________________________________________________ Date______________Adding a new direct deposit or changing account type, financial institution, or account number requires a pre-notification to be sent to the designated financial institution(s). A pre-notification sends your account type, bank ID, and account number to the financial institution to verify the accuracy of information provided. Your first paycheck will be available at the Cashier’s window on the next available pay date. Direct deposit information is available through MyUSI.I hereby authorize the University of Southern Indiana and the financial institutions listed above to initiate direct deposit credit entries of the amounts designated and if necessary debit entries and adjustments from the above accounts to correct errors to my accounts.This agreement is effective on the next payroll processing date and will remain in effect until the University receives notice of change or cancellation by me or until all payroll payments are made resulting from my employment ending at the University. I understand and approve the authorization(s) or cancellation(s) as indicated above. If you participate in the University’s Flexible Spending Account program, and/or are set up with direct deposit through the University’s Accounts Payable department, and this direct deposit change affects either of those programs, please contact the appropriate department to update your direct deposit information.92075369570Attach voided check(s) for checking accounts or a typed letter on the financial institution’s letter head confirming the routing number and the account number for checking or savings account(s).Pre-note On: ____________Verified By: ____________Payroll Effective Date: ____________00Attach voided check(s) for checking accounts or a typed letter on the financial institution’s letter head confirming the routing number and the account number for checking or savings account(s).Pre-note On: ____________Verified By: ____________Payroll Effective Date: ____________Employee Signature__________________________________________Date______________ ................
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