Tennessee Direct Deposit Form 3

Payroll Direct Deposit Authorization Form
To sign up for direct deposit, fill in the blanks, print, sign, and deliver or mail the Payroll Direct Deposit Authorization Form to Human Resource Services (204 Sam H. Ingram Building, Murfreesboro,
TN 37132).
This Direct Deposit Authorization Form does not set students up to receive refunds from the
Business office. The Business office has a separate, online direct deposit process for student refunds.
The Payroll Direct Deposit Authorization Form sets up direct deposit information for all employees:
full-time, part-time, and student employees.
Payday is the last work day of each month except in December. December paydays will vary depending on the calendar but are generally around December 22. Your payment will be deposited into your
account on payday, and your paycheck stub will be e-mailed to your MTSU e-mail account.
If you close your bank account, you must complete a Payroll Direct Deposit Authorization Form cancellation to prevent your money from being sent to a closed account. If you close your bank account
within eight work days of payday, please bring (hand deliver, do not send via campus mail) your cancellation form to the Human Resource office. On payday, you will be glad you did!!! Unless absolutely
necessary, we would encourage you to not close your bank account within eight days of payday. If
you must cancel your account within eight or fewer days of payday, the return of your money from the
bank must be secure before MTSU can issue a replacement check. This could take a few days.
Please call (615) 898-2929 if you have questions.
Print Form
Rev.: 07/2010
Payroll Direct Deposit Authorization Form
Complete form online, print, sign, and deliver or mail to
Human Resource Services, 204 Sam H. Ingram Building, Murfreesboro, TN 37132.
Banner ID Number M_____________________ Name _____________________________________________________
Last
First
Middle
Phone Number (______)___________________ Department _ _______________________________________________
Number where you can be reached between the hours of 8:00 a.m. and 4:30 p.m.
I hereby request that my Middle Tennessee State University payroll check be deposited automatically to my account(s) as indicated, effective on the next payroll
possible. I agree to notify MTSU immediately of any changes to the information so that my pay may be properly distributed and understand that this request may be
cancelled or changed by me upon proper execution of another authorization agreement. This authorization revokes all prior payment direction notifications applicable
to these payments. I understand that in the event MTSU notifies my financial institution that I am not entitled to the funds deposited to my account due to an overpayment or erroneous deposit, my bank is authorized to debit (withdraw transferred funds) my account. I understand that in the event my financial institution is not
able to deposit any electronic transfer into my account due to any action I take, MTSU cannot issue the funds to me until the funds are returned to MTSU by my
financial institution.
I attest that the full amount of my direct deposit is not being forwarded to a bank in another country* and that if at any point I
establish a standing order for my receiving bank to forward the full direct deposit to a bank in another country, I will inform
MTSU immediately.
* This testament is being made as required by the Federal Office of Foreign Asset Control in support of U.S.C. Title 50, War and National Defense.
Employee Signature ______________________________________________ Date_____________________________
Direct Deposit(s) will be made to the following account(s) according to your instructions. If a voided check or financial
institution information form is not attached, Routing Number and Account Number fields MUST be completed. Deposit slips
or debit card numbers CANNOT be used.
Deposit ______ % or $ ___________
of pay to (Direct Deposit no. 1):
Deposit ______ % or $ ___________
of pay to (Direct Deposit no. 2):
Deposit ______ % or $ ___________
of pay to (Direct Deposit no. 3):
Name of Financial Institution
Name of Financial Institution
Name of Financial Institution
Routing Number
Routing Number
Routing Number
Account Number
Account Number
Account Number
Checking
New
Savings
Change
Cancel
Checking
New
Savings
Change
Cancel
Checking
New
Savings
Change
Cancel
Please note that, since a prenotification will be processed through the Automated Clearing House before actual funds are transmitted, new or changed
direct deposits may result in your receiving one physical (paper) check after this form has been submitted. Physical (paper) checks will be available in Cope
Administration Building (CAB) 211 on payday. You must present a valid photo ID to receive your check. Additional (Secondary) accounts need one payroll
cycle to be recognized by the ACH; all funds will be deposited into the primary (Net Pay) account until secondary accounts are active.
Your official MTSU paycheck stub will be sent to your campus e-mail account monthly on the evening before payday. Please retain a copy of this document
each month; it may be required by institutions outside the university for personal financial transactions and/or reporting purposes. If you do not have a
University e-mail account, click here to request one from the Information Technology Division. Additional pay information may be accessed on PipelineMT.
For questions regarding direct deposit, please call (615) 898-2929.
If attaching voided check, please staple HERE.
A Tennessee Board of Regents University
MTSU is an equal opportunity, non-racially identifiable, educational institution that does not discriminate against individuals with disabilities. BF029-0410