University of Southern Indiana
Payroll Direct Deposit Authorization
Please Print
Employee Name: ________________________________________Employee ID #: ______________
Last
First
MI
Direct Deposit #1
Financial Institution _______________________________
Checking
Account Number____________________ Amount Deposited $____________
Savings
OR Percent % ____________
Direct Deposit #2
Financial Institution _______________________________
Checking
Account Number____________________ Amount Deposited $____________
Savings
OR Percent % ____________
Direct Deposit #3
Financial Institution _______________________________
Checking
Account Number____________________ Amount Deposited $____________
Savings
OR Percent % ____________
Direct Deposit #4
Financial Institution _______________________________
Checking
Account Number____________________ Amount Deposited $____________
Savings
OR Percent % ____________
Cancel direct deposit __________________________________________________ Date______________
Adding a new direct deposit or changing account type, financial institution, or account number requires a prenotification to be sent to the designated financial institution(s). A pre-notification sends your account type, bank
ID, and account number to the financial institution to verify the accuracy of information provided. Your first
paycheck will be available at the Cashier’s window on the next available pay date. Direct deposit information is
available through MyUSI.
I hereby authorize the University of Southern Indiana and the financial institutions listed above to initiate direct deposit credit
entries of the amounts designated and if necessary debit entries and adjustments from the above accounts to correct errors
to my accounts.
This agreement is effective on the next payroll processing date and will remain in effect until the University receives notice
of change or cancellation by me or until all payroll payments are made resulting from my employment ending at the
University.
I understand and approve the authorization(s) or cancellation(s) as indicated above.
If you participate in the University’s Flexible Spending Account program, and/or are set up with direct deposit
through the University’s Accounts Payable department, and this direct deposit change affects either of those
programs, please contact the appropriate department to update your direct deposit information.
Employee Signature__________________________________________Date______________
Attach voided check(s) for checking accounts or a typed letter on the financial institution’s letter head confirming
the routing number and the account number for checking or savings account(s).
Pre-note On: ____________
Document1
Verified By: ____________
Payroll Effective Date: ____________
02/24/2011