Spreadsheet: 2adc0f78-ac26-41ef-a349-55d08ea867af
Sheet: Sheet2

ALCORN STATE UNIVERSITY |  |  |  |  |  |  | New to the direct deposit program
PAYROLL DIRECT DEPOSIT AUTHORIZATION |  |  |  |  |  |  | Additions or Changes
See back of form for an explanation of some of the information asked for on this form. |  |  |  |  |  |  | Stop all direct deposits effective
Employee Identification |  |  | Employee Name (Last, First, Middle Initial) |  |  | Department (Abbr. if necessary) |  |  | Telephone Number
 |  |  |  |  |  |  |  |  | [NAME]
Action |  | Priority | Account Type |  | Routing Number | Account Number |  |  | Fill in % or Dollar Amount
 |  |  |  |  |  |  |  |  | Percent of Net Pay
 | Add | 1 |  | Checking
 | Change |  |  |  |  |  |  |  | Dollar Amount
 | Delete |  |  | Savings
Effective Date |  |  | Financial Institution |  |  |  |  |  | City, State
Action |  | Priority | Account Type |  | Routing Number | Account Number |  |  | Fill in % or Dollar Amount
 |  |  |  |  |  |  |  |  | Percent of Net Pay
 | Add | 2 |  | Checking
 | Change |  |  |  |  |  |  |  | Dollar Amount
 | Delete |  |  | Savings
Effective Date |  |  | Financial Institution |  |  |  |  |  | City, State
Action |  | Priority | Account Type |  | Routing Number | Account Number |  |  | Fill in % or Dollar Amount
 |  |  |  |  |  |  |  |  | Percent of Net Pay
 | Add | 3 |  | Checking
 | Change |  |  |  |  |  |  |  | Dollar Amount
 | Delete |  |  | Savings
Effective Date |  |  | Financial Institution |  |  |  |  |  | City, State
Action |  | Priority | Account Type |  | Routing Number | Account Number |  |  | Fill in % or Dollar Amount
 |  |  |  |  |  |  |  |  | Percent of Net Pay
 | Add | 4 |  | Checking
 | Change |  |  |  |  |  |  |  | Dollar Amount
 | Delete |  |  | Savings
Effective Date |  |  | Financial Institution |  |  |  |  |  | City, State
Action |  | Priority | Account Type |  | Routing Number | Account Number |  |  | Fill in % or Dollar Amount
 |  |  |  |  |  |  |  |  | Percent of Net Pay
 | Add | 5 |  | Checking
 | Change |  |  |  |  |  |  |  | Dollar Amount
 | Delete |  |  | Savings
Effective Date |  |  | Financial Institution |  |  |  |  |  | City, State
PLEASE ATTACH A VOIDED CHECK OR A DOCUMENT PRE-PRINTED FROM YOUR FINANCIAL INSTITUTION VERIFYING THE INSTITUTION'S
ROUTING NUMBER AND YOUR ACCOUNT NUMBER FOR ACCURACY.  STARTER CHECKS ARE PERMISSABLE.  NO MORE THAN 5 ENTRIES PER
EMPLOYEE.
A prenote may be required for new employees and for employees making changes to their direct deposit. A prenote sends
your account type and numbers to the bank without any money to assure accuracy regarding account information entered
in the system.  If a prenote is applied, you will receive an actual check and the next check will be direct deposit.
Comments:  Any time you change your direct deposit, you must make your changes very clear to the staff that will process
the changes.  Use this space, if necessary, to describe what you want to occur.  This will help make your changes turn out
the way you expect.
I authorize the Payroll Office to initiate electronic credit entries (direct deposits) for the amounts  designated to the
financial institution(s) indicated above.  I further authorize, if necessary, debit entries and/or adjustments for any credit
entries made in error to the accounts specified above.  I understand that my direct deposit can be discontinued at any time
due to infringement of University policy, procedure, or practice.
Employee Signature |  |  |  |  |  |  | Date
Payroll Direct Deposit Authorization Form Instructions
Boxes in the upper right-hand corner of the form:  Check the applicable box.  To delete all direct  deposits, check the stop box then
 | sign and date the form.
Employee Identification #:  Although SSN numbers can be used here, we encourage use of your Alcorn ID number as an identifier.
 | This action can aid in the protection of your identify.  Your Alcorn ID number is located on the back of your ASU Gold Card.
Department, Work Phone, and Email Address:  Please fill in the department in which you work, a reliable phone number, and
 | email address.  This will help us contact you if we need additional information concerning your authorization or encounter
 | problems with your account(s).
Priority Number:  Indicate which direct deposit account should receive funds first, second, third, etc.
 | Note:  All discriminate dollar amounts should come first and if all the remaining amount of money is going to the final account
 | then 100% should be listed on the last priority.  This means that 100% of the remaining balance goes to that final account.
Account Type:  Check the appropriate account type for your institution(s).  If you are unsure of the account type, please contact
 | your financial institution(s).  Incorrect entries can delay receipt of funds up to five (5) business days.
Routing and Account Numbers:  Generally, the routing number to your financial institutions is the nine (9) digit number located on
 | the bottom left-hand corner of your check followed by your account number.  Some financial institutions may differ.  Be careful not
 | to include the check number which is located on the same line.  If you are unsure of these numbers, please contact your financial
 | institution(s) to confirm these numbers before submitting this form for processing.  Incorrect entries can delay receipt of funds
 | up to five (5) business days.
Percent of Net Pay or Dollar Amount:  Each direct deposit entry must have either a percent of net pay or dollar amount entered.
City, State:  The city and state where the account was established.
Comments:  While the comments section is optional, we encourage utilization of this section to ensure accuracy.
Employee Signature, Date:  It is imperative that this form is dated and signed by the employee.  Failure to do so will delay processing.
Please remit all direct deposit authorization forms to the Payroll Office for processing.
For additional questions or information regarding direct deposit, please contact the following:
Mrs. [NAME] |  |  | Director of Payroll/Accountant |  |  | [PHONE] |  |  | [EMAIL]
Ms. [NAME] |  |  | Assistant Coordinator of Payroll |  |  | [PHONE] |  |  | [EMAIL]
 |  |  | Fax |  |  | [PHONE]
 | Note:  If emailing, please indicate Direct Deposit on the subject line.
Notice:  All data on this form is private, except for biographical information provided at the top of the form.  The private
data is not legally required; however, by not providing it, your direct deposit transaction will not be assured of going to
the correct financial institution, to the correct account or that the correct amount will be posted accurately.  The private
data listed on this form is available to representatives of your agency and employees of the State who perform personnel
or payroll related functions, provided such individuals have a business reason to access the data.  Others who may
legally access this information are representatives of the Attorney General's Office, enforcement agencies with the
statutory authority and persons/entities authorized by law or court order.