Credit Authorization to Indiana University for Direct Bank Deposit Service

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Instructions

  1. Fill in the form within your browser.
  2. Print the completed form using your browser. Use File/Print.
  3. Sign and date the form in the space provided.
  4. MAIL THE COMPLETED FORM TO YOUR CAMPUS PAYROLL DEPARTMENT.
Name:
Campus Phone Number:
IU Employee ID Number:
Enter last 4 digits of Social Security Number:
(New IU Employees Only)
Pay Schedule:
START depositing my net earnings on all payrolls into my checking or savings account(s) (see below).
STOP depositing my net earnings on all payrolls into my checking or savings account(s) (see below).
CHANGE my bank(s) and checking or account number(s) as shown below. My net earnings are now being deposited.

FOR CHECKING OR SHARE DRAFT ACCOUNT(S), VOIDED CHECK(S) MUST BE ATTACHED
FOR SAVINGS ACCOUNT(S), DEPOSIT SLIP(S) MUST BE ATTACHED
NOTE: You may designate direct deposit by either percent or amount, but not both. This direct deposit information will be used to distribute ALL payroll payments from IU.

Bank Information

1) Name of Financial Institution:
Address:
City:  State:
Zip:  Bank Routing Number (ABA):
  *Percent           or            Amount
  (NOTE: If you enter an amount, a second financial institution MUST be entered below and the remaining balance box must be checked.)
Type of Account:  Account Number:
2) Name of Financial Institution:
Address:
City:  State:
Zip:  Bank Routing Number (ABA):
 

*Percent           or            Remaining Balance

Type of Account:  Account Number:
*NOTE: Total Percent must equal 100
I certify that I am the owner, or joint owner, of the account(s) designated and am entitled to provide this authorization. I authorize Indiana University to initiate electronic credit entries, and if necessary, debit entries and adjustments for any credit entries in error to my account(s) listed above. This authorization will remain in effect until Indiana University receives written notice of direct deposit termination from me, in such time and manner as to afford reasonable opportunity for Indiana University and the Financial Institution(s) to act on it. I understand that the very earliest I can expect my checking or savings account(s) to be credited will be on payday. Also, if I change or terminate my account(s) without notifying IU Payroll in writing, I understand that my pay may be delayed. This authorization may be discontinued only by my written request, or automatically two years following my termination of all employment with IU.
Signature Campus Phone Number Date

Rev. June, 2004