Fillable Printable Direct Deposit Authorization Form - Southern Illinois University Carbondale

Direct Deposit Authorization Form - Southern Illinois University Carbondale

PAO 0100

05/13

Page of

DIRECT DEPOSIT AUTHORIZATION FORM

SOUTHERN ILLINOIS UNIVERSITY CARBONDALE

SECTION 1: PERSONAL INFORMATION

I am a (select one):

Monthly-paid Employee (Faculty, AP Staff, Grad/Undergrad Assistant)

Semimonthly-paid Civil Service Employee

Biweekly-paid Civil Service Employee

Biweekly-paid Student Employee

Last Name:

First Name:

MI:

Phone Number (Daytime):

Email Address:

NOTE: Student employees may view a

statement of earnings on Salukinet.

Last 4 digits of Social Security Number:

X X X - X X -

Name of Financial Institution:

Address of Financial Institution (City, State):

Account Type:

Checking

Savings

Transit / Routing Number:

Account Number:

Attach a VOIDED

check to the

left margin of this

area

(optional).

Send completed form to:

Human Resources - Payroll

Miles Hall, Mail Code 6520

Southern Illinois University

1255 Douglas Drive

Carbondale, IL 62901

SECTION 3: AUTHORIZATION

I authorize Southern Illinois University Carbondale to direct my recurring payments for crediting (deposit) in the account indicated at the financial

institution designated above and to initiate, if necessary, debit entries and adjustments for any credit entries in error to the account indicated above.

Deposit payments include, but are not limited to, travel/expense reimbursement and employment pay (payroll). This authorization is not an assignment of

my right to receive payment and revokes all prior payment directions applicable to these payments. I understand that the financial institution designated

or Southern Illinois University reserves the right to cancel this agreement by notice to me.

Signature: _______________________________________________________________

Date:

For SIU use only: Activated in system by (initials): ________ on: ________ HRMS Assignment #: ______________

SECTION 2: BANK ACCOUNT INFORMATION

In order to comply with the US Office of Foreign Assets Control (OFAC) and National Automated Clearing House Association

(NACHA) regulations, you must notify the University Human Resouces Payroll area if you receive a payment from the University

via direct deposit at a US financial institution and forward the entire amount to a financial institution in a foreign country.