REVISED UP DIRECT DEPOSIT OPT OUT FORM

UNIVERSITY OF PORTLAND
DIRECT DEPOSIT EXEMPTION FORM
Banner ID _____________________________
Name ________________________________________
(Please print)
The University of Portland expects that all employees and students establish a direct deposit relationship with the
University. This promotes sustainability on campus; eliminates the possibility of lost checks; and enables faster, more
secure deposits while reducing the possibility of theft and fraud. Any domestic bank is acceptable.
Exemption Request (To be completed by individual requesting to be exempted from receiving payments via direct deposit)
I request that I be paid by paper check for the following reason:
□ I do not have an account at a United States financial institution.
□ Other (please describe) _______________________________________________________________________
Individual Acknowledgements:
By electing to opt out of direct deposit, a paper check will be generated and mailed to my designated address for
distribution. Paychecks will not be disbursed earlier than the designated payment date for the pay period.
The University assumes no responsibility for the delay in receiving a paper check via the United States Postal Service or
equivalent service. Should a paper check have to be reissued due to a lost check, the individual may have to wait up to
10 business days before a replacement check will be issued and mailed. A $50 fee will also be assessed for any checks
that are reissued, unless the individual completes the necessary direct deposit information.
By signing below, I acknowledge the above and hereby submit my request for exemption.
Signature ________________________________________________
Date ______________________________
Instructions:
Please submit this form to the following address:
University of Portland
Attn: Office of the Controller MSC 167
5000 N. Willamette Blvd
Portland, OR 97203
[email protected]
Office of the Controller Use Only:
Received by: ___________________________________________ Date: _________________________________