Fillable Printable Direct Deposit Authorization - Florida State University

Direct Deposit Authorization - Florida State University

Form Purpose: To start, change or stop direct deposit for all the following payments received from Florida State

University: Payroll, Employee Travel Reimbursements, Nonresident alien non-qualified scholarships, Nonresident alien

honorarium payments.

Employee payroll payments can be distributed between two different bank accounts and can be managed by the

employee through the Self-Service module in the OMNI system. Please note employee travel reimbursements will be

deposited into only the primary bank account listed in the OMNI system.

Check One:

Employee I.D. or Vendor E.I.N.

Full Legal Name

Direct Deposit Action (Check One):

Account Type (Check One):

Account # :

Name of Financial Institution

Office of the University Controller

Florida State University

Payroll Services

5600A University Center

Tallahassee, FL 32306-2391

Ph: (850) 644-3813 Fax: (850) 644-9403

DIRECT DEPOSIT AUTHORIZATION

NOTE: This form must be completed IN ITS ENTIRETY in order to be processed.

Employee Vendor

(DO NOT USE SS #)

Date of Birth Phone Number

Start Change Stop

Checking Savings

ACH Transit/Routing # :

(Must be nine digits)

Please confirm the following information with your financial institution.

Phone Number

Special Note: Please ensure your direct deposit information has been updated in OMNI to a new account before

closing your existing account. Otherwise, the funds will be returned to FSU and there could be a seven to ten day delay

before you receive your payment. Direct deposit information entered into the OMNI system takes effect immediately, so

please ensure your information is correct. FSU is not liable for any incorrect information submitted by the employee on

this form (e.g., account number, routing number, employee identification/vendor number).

PR-06 Revised 05/13

____________________________________

______________________________

Signature

Date

●

I, the undersigned, hereby authorize and request Florida State University to initiate credit entries and, if

necessary, a debit entry in accordance with NACHA rules reversing a credit entry made in error, to my account at the named

financial institution.

● This direct deposit authorization is to remain in effect until changed by: (a) me, either through employee self-service or in

writing; (b) my legal representative, in case of my legal incapacity; (c) the financial institution; or (d) Florida State University.

●

Any request to update my direct deposit information outside the self-service applications must be in writing.The change will be

effective with the next available payroll cycle. This election will remain in effect until the option is cancelled.

●

I further understand I am responsible for notifying FSU Paroll Services in writing if I transfer the full amount of my received direct

deposit to a foreign bank account. This is in accordance with NACHA rules to comply with the requirements of the Office of Foreign

Assets Control (OFAC).

● My signature below signifies acceptance of the terms and conditions stated above.