Fillable ACH Direct Deposit Form - Revised 07-13-2012 Fillable

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ACH Direct Deposit Form - Revised 07-13-2012 Fillable

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Type of Action (Please Check One)
New Change Cancel
Individual Company
I am currently a State employee
______________________
FEIN# ______________________________________
Banner I. D. __________________________
(Federal Employee Identification Number)
Name: ____________________________________
Organization: ________________________________
Address: ____________________________________
Address: ____________________________________
Name: ______________________________________
Title: _______________________________________
Employee No. ______________________________
Preferred Notification is via e-mail.
I have read, understand and agree to the Terms and Conditions on page 2.
Non-payroll: Purchasing at 860.832.2530 Payroll at 860.832.2520
Payroll ____________________________ Purchasing ________________________
Page 1
_________________________________________
City, State and Zip Code
Phone : ( ) ____________________________
Street
Street
_________________________________________
Direct Deposit and ACH Payment
INDIVIDUAL/COMPANY INFORMATION
Retain a copy of this agreement
for your records.
Submit original form to:
ACH/Direct Deposit Unit
CCSU Business Office
Marcus White Annex 006
Fax# 860.832.2522
For Business Office Use Only (Initial and Date Receipt of Form)
City, State and Zip Code
Phone : ( ) ____________________________
NOTIFICATION METHOD - FOR NON-PAYROLL CHECKS
Payroll Office Use Only
Pay Period: ______________________________
Type of Account : Savings Checking
FINANCIAL INSTITUTION INFORMATION
Signature: ________________________________________________________ Date: _______________
Bank Account Number: __________________________________________________
Nine-Digit Bank Routing Number:
(Primary) E Mail Address: _________________________________________________
(Secondary) Fax No.: __________________________________________________
If you have any questions concerning ACH transactions, please contact:
Bank Name: ______________________________________________________________
Non Payroll ACH:
Payroll ACH:
07.13.12
Page 2
In the event my employment with the State is terminated for any reason whatsoever, and if at the time of such termination
I have had unearned pay automatically deposited in my checking/savings account, I will immediately repay such
unearned pay, I will be personally liable for all costs of collection, including reasonable attorney's fees incurred by the
State in the collection of such unearned pay, together with the maximum interest by law. I must notify the Personnel
Office three (3) weeks in advance of closing the above account. If I fail to do so, I understand that it may take up to two
(2) weeks to recover funds sent to a closed account.
TERMS AND CONDITIONS
In the event that the State notifies the bank that the funds, which I did not earn, have been deposited to my account in
error, I hereby authorize and direct the bank to return said funds to the State as soon as possible. In the event such
unearned funds have been drawn from that account so that return of those funds by the bank to the State is not possible,
I hereby authorize the State to recover those funds by deducting the amount of said unearned funds from any future
salary payments from the State until the amount of the unearned deposit has been recovered in full.
Submission of the Direct Deposit and ACH Payment Enrollment Form authorizes Central Connecticut State University to electronically
deposit payments through the Federal Automated Clearing House (ACH) to the bank listed on page one pertaining to payroll checks,
travel, refunds, refunds (including Title IV) and vendor (company or individual), whichever is applicable.
This authorization is to remain in full force and effect until vendor (company or individual) provides advance written
notice of termination or in such a time and manner to afford the State and the bank named on page one a reasonable
opportunity to act on it. It is the sole responsibility of the vendor (company or individual) to stop such transactions.
CCSU may reverse any duplicate or erroneous credit entry.
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ACH Direct Deposit Form - Revised 07-13-2012 Fillable

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Completed 3 November 2019

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