Online Pay Stubs “Opt Out” Request Form

| Accounting & Business Services
2130 Fulton Street | Lone Mountain North 3rd Floor West San Francisco, CA 94117-1080 | Phone 415.422.6521 | Fax 415.422.2530
Payroll Direct Deposit Authorization Agreement
Employee Name:
(Please Print)
USF ID #
(Located on USF Connect/Paycheck):
1.
Complete all required information.
2.
Attach a current VOIDED CHECK for a checking account or a savings deposit slip for a savings account.
Forms without the appropriate attachment will be returned.
3.
Return all requested forms to:
University of San Francisco
Payroll Office – Accounting & Business Services
2130 Fulton Street
Lone Mountain North 3rd Floor
San Francisco, CA 94117-1080
Select One:
ENROLL
CHANGE
CANCEL
By checking here, I elect to waive the standard 30 day pre-note period. I understand that if the funds are
routed incorrectly, they will not be recovered until the original funds are returned.
Financial Institution Name:
CHECKING
SAVINGS
Routing Number:
Routing Number:
Account Number:
Account Number:
Deposit Amount: ______ 100% Net (or)
Deposit Amount: ______ 100% Net (or)
$______ Flat Amount (enter amt.)
$______ Flat Amount (enter amt.)
x
Signature
Date of Request
FOR PAYROLL USE ONLY
Date Received
Date Processed
Completed By
Payroll
07/28/2016)