Complete Sections 1 and 2 to authorize Direct Deposit.
Complete Section 3 to cancel Direct Deposit.
Email this form to ltupayments@ltu.edu or return it to the OneStopCenter on campus.
STUDENT’S NAME: __________________________________________ STUDENT ID:__________________
1. STUDENT AUTHORIZATION AGREEMENT FOR DIRECT DEPOSITS (CREDITS) (please print clearly)
(Authorizations will be retained on file until you wish to rescind or change this form.)
Name on Account (Student): ________________________________________________________________
Student’s Financial Institution: _______________________________________________________________
City: ____________________ State: ________ Type of Account (check one): Checking Savings
Bank Routing Number / ABA Number (9 digits)* __ __ __ __ __ __ __ __ __ (Found on bottom left portion of check)
Account Number: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Please attach a voided check with the account number and bank ABA number. Be sure to write “VOID” on your sample
check submitted.
2. CERTIFICATION STATEMENT (Signature Required)
By signing this form, I authorize Lawrence Technological University and my financial institution identified above, to
automatically deposit the financial aid refund to the account designated.
Student Signature Date
3. CANCEL DIRECT DEPOSIT AUTHORIZATION (Signature Required)
(If you have closed your bank account and this information is no longer valid, you will need to cancel the Direct
Deposit Authorization.)
By signing this form, I authorize Lawrence Technological University to delete financial institution identified above.
Student Signature Date
