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. 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 change your account information via your Pipeline account or 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.: 04/2015 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) 103 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. 0315-1685 – Middle Tennessee State University is an AA/EEO employer and does not discriminate on the basis of race, color, national origin, sex, disability, or age in its programs and activities. The following person has been designated to handle inquiries regarding the nondiscrimination policies: Executive Director of Institutional Equity and Compliance, 1301 E. Main Street, CAB 220, Murfreesboro, TN 37132, 615-898-2185. Additionally, the MTSU Title IX Coordinator, designated to monitor and oversee Title IX complaints, may be contacted at: Sam Ingram Building, 2269 Middle Tennessee Blvd., Murfreesboro, TN 37132 615-898-5133, or via this webpage: http://www.mtsu.edu/titleix/.
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