Direct Deposit Authorization Form
Payroll and Employee Reimbursement
Name
ID or SS#
Address
Phone No. (Home) (Work)
VSCC Email Address (for email notification)
Please check one:
Routing Transit No
Acct No
Routing Transit No Acct No
Routing Transit No Acct No
Routing Transit No Acct No
•
There may be up to sixty (60) days administrative processing before enrollment will become effective.
•
It is your responsibility to notify Volunteer State Community College Human Resources office or Payroll Office of any
changes in your account, such as account closure or change in account number.
•
This agreement may be cancelled by your financial institution or Volunteer State Community College. VSCC reserves the
right to automatically cancel your participation in the direct deposit program upon termination of employment.
•
You must provide a blank voided check or a direct deposit form from your financial institution with
the required information for direct deposit. A deposit slip may not be acceptable documentation.
I authorize Volunteer State Community College to initiate credit entries to the account(s) indicated for the purpose of depositing
personal reimbursement. I also authorize Volunteer State Community College to initiate, if necessary, debit entries and
adjustments for any credit entries made in error.
Signature ____________________________________________________________Date _____________________________
Financial Institution Name
Financial Institution Name
Financial Institution Name
Financial Institution Name
5. Employee Reimbursement Deposit:
Routing Transit No Acct No
Financial Institution Name
New
Change
Other
Checking
Savings
New
Change
Cancel
New
Change
Cancel
New
Change
Cancel
New Change
2. Fixed Dollar Amount Deposit: Amount $
3. Fixed Dollar Amount Deposit: Amount $
4. Fixed Dollar Amount Deposit: Amount $
Savings
Checking
Other
Other
Checking Savings
Savings
Checking
Other
Checking Savings
Other
Employee reimbursements will default to Net Pay Deposit account unless designatd below.
1. Net Pay Deposit
Revised July 2013
Adjunct
Part Time Hourly
Other
Full Time
