Fillable AS35 I (Louisiana State University)

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AS35 I (Louisiana State University)

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U.S.A. forms for Louisiana State University

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Rev 08/07
Louisiana State University
Office of Accounting Services
Payroll
204 Thomas Boyd Hall
AUTHORIZATION AGREEMENT FOR ACH INSURANCE DEDUCTIONS AS35-I
Employee ___________________________ __________________________________ ________
Last First MI
Action New Change LSU ID ___________________________
I hereby authorize Louisiana State University (LSU) to initiate debit entries for this transaction to the account at the indicated financial
institution, and I hereby authorize the indicated financial institution to accept and to post such entries to my account.
This authorization is in effect until I cancel such authorization by delivering written notice of cancellation to LSU Office of Accounting
Services, Payroll, 204 Thomas Boyd Hall, with sufficient time to afford LSU and the financial institution a reasonable opportunity to
take the requested action. This authorization may be canceled at any time.
I hereby authorize LSU to provide a copy of the authorization to any institution participating in NACHA and the Southern Financial
Exchange.
________________________________________ _______________________
Signature Date
- - - - Tape this edge - - - -
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
FOR ACCOUNTING SERVICES USE ONLY
Entry Code ________ Processed by ___________________________________ Date ___________________________
Bank
City
State
Zip
Bank Transit #
Account #
Account Type
Checking Savings
For account verification, attach a voided check.
DO NOT USE STAPLES
- - - - Tape this edge - - - -
- - - - Tape this edge - - - -
Rev 11/12
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AS35 I (Louisiana State University)

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Completed 21 July 2020

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