PLEASE CHECK
New Change
Payroll Unit
Direct Deposit Authorization
PRINT LAST NAME, FIRST NAME, MIDDLE INITIAL SOCIAL SECURITY NUMBER
NAME OF SCHOOL DISTRICT (IF EMPLOYED WITHIN THE OFFICE, PUT YOUR ROOM NUMBER HERE) WORK TELEPHONE NUMBER
( )
NAME OF BANK/CREDIT UNION/SAVINGS & LOAN BRANCH TELEPHONE NUMBER
( )
Checking
Savings
ACCOUNT NUMBER ADDRESS OF BANK/CREDIT UNION/SAVINGS & LOAN (NUMBER,STREET,CITY AND ZIP CODE)
I hereby authorize the district and the Los Angeles County Office of Education (LACOE) and/or its agents to initiate electronic
deposits and, as necessary, debit corrections to previous deposits to my account.
I understand:
Direct deposit status is not activated until 10 days following a
$0 test transaction for new or change authorization.
Direct deposit will also be suspended if a a certificated
employee's credential expires.
I must submit a new Employee's Direct Deposit Authorization,
Form No. 501-508, if I change my account
(name, institution, branch, type account, etc.).
Direct deposit status may be suspended or rescinded by
the district or LACOE and payment made by county
warrant, if necesasry, to meet payroll deadlines or under
extreme conditions.
Direct deposit status will be temporarily suspended if wages
are garnished.
I agree to hold harmless and indemnify the district and Los Angeles County Office of Education and its officers, employees, and agents
from any claim or demand of whatever nature, including those based upon negligence of LACOE and its officers, employees, and
agents for failure or delay in making deposits and/or corrections to deposits as herein authorized.
This authorization replaces any previously made by me and is to remain in effect until changed or canceled by submission of a new
Employee's Direct Deposit Authorization.
ATTACH BELOW A VOIDED CHECK
SHOWING THE INSTITUTION ROUTING
NUMBER AND ACCOUNT NUMBER.
SIGNATURE OF EMPLOYEE
x
DATE SIGNED
ATTACH VOIDED CHECK HERE
FOR COUNTY OFFICE USE ONLY
Refer to the Direct Deposit Reference Guide
INPUT BY (PRINT NAME)
FINANCIAL INSTITUTION ROUTING NO.
EMPLOYEE'S DEPOSIT ACCOUNT NO.
GR 9/2007
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