Massachusetts Direct Deposit Form 2

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Direct Deposit Authorization Form
EmplID
HR EmplD __ __ __ __ __ __ __ __
University of Massachusetts – Amherst
our EmplID is 8 digits long. Please write your SSN above only
if you have not yet been paid by the University thus do not
have an EmplID. Thank you.
Name ________________________________________________________________________
Phone ___________________ Email ________________________________________________
Action Requested (Check
One)
Start Direct Deposit
Stop Direct Deposit
Change (add/delete a bank, increase/decrease
fixed amount or select new balance account)
* A change replaces the direct deposit authorization currently on file. Fill in every row of bank information to show how your check should be deposited.
Bank Name
Routing #
__ __ __ __ __ __ __ __ __
Full Deposit
or
Fixed Amount
Checking
(9 digits)
or
Savings
Acct# _____________________
Balance Account
Deposit any balance of net
pay to this account
$_____________________
If depositing more than one (1) bank, you must choose one Balance Account.
Bank Name
Routing #
__ __ __ __ __ __ __ __ __
(9 digits)
or
Savings
Acct# _____________________
Bank Name
Balance Account
Deposit any balance of net
pay to this account
$_____________________
Routing #
__ __ __ __ __ __ __ __ __
Full Deposit
or
Fixed Amount
Checking
(9 digits)
or
Savings
Acct# _____________________
Bank Name
Full Deposit
or
Fixed Amount
Checking
Balance Account
Deposit any balance of net
pay to this account
$_____________________
Routing #
__ __ __ __ __ __ __ __ __
Full Deposit
or
Fixed Amount
Checking
(9 digits)
or
Savings
Acct# _____________________
Balance Account
Deposit any balance of net
pay to this account
$_____________________
I authorized the University of Massachusetts to deposit my net pay via direct deposit to my account(s) as indicated above. If funds to which I am
not entitled are deposited to my account(s), I authorize the University to direct the financial institution(s) to return said funds.
I understand that it is my responsibility to verify that payments have been credited to my account(s) and that the University assumes no liability
for overdrafts for any reason. I understand that in the event my financial institution(s) is/are not able to deposit any electronic transfer into my
account due to any action I take, the University cannot issue to funds to me until the funds are returned to the University by my financial
institution(s).
I understand this authorization will override any previous authorization and will remain in effect until a( revoked by my written request; or b)
immediately following my termination from employment with the University; or c) 120 days after my last paycheck was issued.
I understand I must immediately notify the Payroll Office before I close any/all account(s) listed above while this authorization is in effect.
Employee Signature ________________________________________ Today’s Date __________________________
Attach a voided check and/or deposit slip for each new account entered above.
Bring or send the completed Authorization form with attached check(s)/deposit slip(s) to:
rd
Human Resources, 3 floor, Whitmore Administration Building.
Please allow up to five (5) weeks (2 pay cycles) for this authorization to take effect.
Questions? Call the Payroll Office, (413) 545-3761 or 545-0391