Fillable CCCCD Direct Deposit Form

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CCCCD Direct Deposit Form

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The CCCCD Direct Deposit Form form is 1 page long and contains:

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  • 6 check-boxes
  • 13 other fields

Country of origin: US
File type: PDF

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CONTRA COSTA COMMUNITY COLLEGE DISTRICT
DIRECT DEPOSIT AUTHORIZATION
New or Change Cancel Bank Merge
NAME:
SOCIAL SECURITY NUMBER:
HOME PHONE:
WORK PHONE & CAMPUS CCC DVC LMC DST
NAME OF FINANCIAL INSTITUTION:
BRANCH NUMBER/LOCATION:
ADDRESS OF FINANCIAL INSTITUTION:
BRANCH PHONE NUMBER:
ROUTING NUMBER:
ACCOUNT NUMBER CHECKING SAVINGS
I hereby authorize the above named Contra Costa Community College District (CCCCD) and their agents, to
initiate electronic deposits and as necessary, debit corrections to previous deposits, to the above account.
I understand,
Direct Deposit is not activated for 31 days following a Prenote, verified by Wells Fargo Bank for
new or change authorization.
I must submit a new authorization form if I change my account (name, branch, type of account,
etc.)
I will pay any charges caused by my failure to submit a new authorization form for any account
change.
Direct Deposit status may be suspended or rescinded by the CCCCD and payment made by
warrant, if necessary to meet payroll deadlines or under other extreme conditions.
I agree to hold harmless and indemnify the CCCCD and their officers and employees from any claim or demand
of whatever nature of failure or delay in making deposits and/or corrections to deposits herein authorized.
This authorization replaces any previously made by me and is to remain in effect until changed or cancelled by
submission of a new Direct Deposit Authorization Form.
Signature
Date
ATTACH VOID CHECK HERE
District Payroll Use Only
Processed by
Date
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CCCCD Direct Deposit Form

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Completed 28 February 2020

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