CALIFORNIA STATE UNIVERSITY, LOS ANGELES
EMPLOYEE REIMBURSEMENT DIRECT DEPOSIT
ENROLLMENT AUTHORIZATION
SEE INSTRUCTIONS AND PRIVACY NOTICE FOR ADDITIONAL INFORMATION.
USE BALL POINT PEN - PRINT CLEARLY.
SECTION A (To be completed by employee)
1. TYPE OF ENROLLMENT ACTION (Select one)
2. EMPLID (Include all 9 digits)
a. NEW (SECTIONS A, B, AND C MUST BE COMPLETED ) **
b. CHANGE (SECTIONS A, B, AND C MUST BE COMPLETE D)**
3. NAME (First) (Middle) (Last)
CANCEL (SECTIONS A AND D MUST BE COMPLETED )c.
4. DAYTIME PHONE NUMBER 5. EMAIL ADDRESS
SECTION B (To be completed by employee if NEW or CHANGE box in Section A is checked )
1. TYPE OF ACCOUNT- MUST BE CHECKED- IF LEFT BLANK, WILL BE PROCESSED AS CHECKING
C (Checking) S (Savings)
2. BANK ROUTING NUMBER (Cannot exceed 9 digits) 3. BANK ACCOUNT NUMBER (Cannot exceed 17 digits)
4. FINANCIAL INSTITUTION NAME
5. FINANCIAL INSTITUTION ADDRESS (Optional)
Number and Street City State Zip Code
SECTION C (To be completed by employee if NEW or CHANGE box in Section A is checked)
SIGNATURE DATE
SECTION D (To be completed by employee if CANCEL box in Section A is checked)
I hereby cancel my Direct Deposit authorization. SIGNATURE DATE
This authorization remains in full force and effect until Controller's Office Accounts
Payable receives written notification from the employee of its cancellation.
See Instructions for Helpful Tips on Locating Your Bank Routing and Account Information
Please send completed form to: Controller's Office
5151 State University Drive, Adm - 514, Los Angeles, CA 90032
Attn: Accounts Payable
Read Statement Carefully: I hereby authorize California State University, Los Angeles to credit any reimbursements due to me to the
bank account referenced above. I also authorize California State University, Los Angeles to recover any overpayment of reimbursements
from the above referenced bank account. This authorization will remain in effect until cancelled in writing. A new authorization form will be
completed if I change my bank account, close my bank account, or change financial institutions.
Print Form
Clear Form
EMPLOYEE REIMBURSEMENT DIRECT DEPOSIT INSTRUCTIONS
PLEASE READ THIS INFORMATION CAREFULLY
COMPLETION INSTRUCTIONS
1. To enroll in Employee Reimbursement Direct Deposit, complete this form as follows:
General Instructions
Complete Sections A, B, and C if you are enrolling for the first time, re-enrolling after cancellation, or changing
your existing Employee Reimbursement Direct Deposit information.
Complete Section A and D only if you are cancelling your enrollment.
Specific Instructions
Section A
(Item 1) Type of Enrollment Action
New - Complete for new enrollment or re-enrollment after cancellation
Change - Complete to change type of account, financial institution or bank routing number, or bank account
number.
Cancel - Complete to cancel your Employee Reimbursement Direct Deposit
(Item 2) EMPLID
The EMPLID Number is a 9 digit number assigned to all employees of CSULA. All numeric digits are required,
including “0”. This number can be found on your CSULA Employee ID Card.
(Item 3) NAME
Complete the name field with your full leg
al name. Please note that your name must match the name on
file with your financial institution.
(Item 4) DAYTIME PHONE NUMBER
Provide a daytime telephone number where you can be reached during business hours.
(Item 5) EMAIL ADDRESS
Provide an email address where you would like to receive your Employee Reimbursement Direct Deposit
notifications.
Section B (Item 1) Indicate checking OR savings. Only one box must be checked. If left blank, will be processed as
checking.
(Item 2) Enter
Bank Routing Number (cannot begin with a ‘5’ and cannot exceed 9 digits).
See page 2 for Helpful Tips on Locating Your Bank Routing and Account Information.
(Item 3) Enter Bank Account Number (cannot exceed 17 digits).
See page 2 for Helpful Tips on Locating Your Bank Routing and Account Information.
(Item 4) Enter Financial Institution Name.
(Item 5) Enter Financial Institution Address (optional).
2. Deliver your completed form to the Controller's Office or Fax to (323) 343-3650 Attn: Controller's Office
EM
PL
OYEE REI
MB
UR
SEMENT DIRECT DEPOSIT POSTING DATES
While most financial institutions post funds to
accounts at the beginning of the bank business day, this is not a universal
practice. Some institutions
post funds in the afternoon instead of the morning. It is strongly recommended that you check with
your financial institution to determine when your funds will be available.
CHANGING FINANCIAL INSTITUTION OR BANK ACCOUNTS
Your Employee R
eimbursement Direct Deposit will continue to be deposited into your designated account at your financial
institution until the Controller’s Office is notified that you wish to change your bank account number and/or your financial
institution. To change, complete and submit
a new Employee Reimbursement Direct Deposit form with the new information.
DO NOT CLOSE YOUR OLD ACCOUNT UNTIL YOUR FIRST PAYMENT IS
DEPOSITED INTO YOUR NEWLY DESIGNATED ACCOUNT
AND/OR FINANC
IAL I
NSTITUTION.
PRIVACY NOTICE
The Information Practices
Act of 1977 (Civil Code Section 1798.17) and the Federal Privacy Act (Public Law 93-579) require that
this notice be provided when collecting personal information from individuals. Information requested on this form is used by
the California State University, Los Angeles Controller's Office
for the purposes of identification and enrollment processing. It
is mandatory to furnish all information requested on this form except for
financial institution name and address. Failure to
provide the mandatory information may result in the enrollment
action not being processed or being processed incorrectly.
Where are my Bank Routing and Bank Account
N
umber
s
?
The line of numbers and special symbols at the bottom of one of your personal checks or deposit slips contains the
bank routing and bank account number information you need to enter on the form.
Example 1: Sample
Check
Example 2: Sample Deposit
Slip
Bank Routing Numbers
Your bank routing number is the nine digit number which appears between the symbols on the bottom of your
check.
Bank Account Numbers
Your bank account number usually appears to the right of the bank routing number. It can be up to 17 characters
long and contains only digits and possibly hyphens. If the bank account number printed on your check contains
spaces, you do not need to enter the spaces.
Note: Some banks display the check number to the left of the bank account number. Be sure you do not include
the check number as part of the bank account number.
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