Fillable Direct Deposit Form-revised-050719 3

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Direct Deposit Form-revised-050719 3

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LAMAR STATE COLLEGE - PORT ARTHUR
AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT
76-0658056
I authorize Lamar State College Port Arthur to credit my account with the depository named below.
In the event that funds are deposited into my account in error, I authorize LSCPA to initiate the necessary de
bit
entries, not to exceed the total of the original credit amount.
DIRECT DEPOSIT ONE
Financial Institution Name
Bank Savings and Loan
Credit Union Other
Transit/ABA Number
City State Zip Code
Checking
Saving
Amount $
%
Account Number
Do you designate this account for direct deposit for Travel Reimbursement? Yes No
DIRECT DEPOSIT TWO
Financial Institution Name
Bank Savings and Loan
Credit Union Other
Transit/ABA Number
City State Zip Code
Checking
Saving
Amount $
%
Account Number
Do you designate this account for direct deposit for Travel Reimbursement? Yes No
DIRECT DEPOSIT THREE
Financial Institution Name
Bank Savings and Loan
Credit Union Other
Transit/ABA Number
City State Zip Code
Checking
Saving
Amount $
%
Account Number
Do you designate this account for direct deposit for Travel Reimbursement? Yes No
DIRECT DEPOSIT FOUR
Financial Institution Name
Bank Savings and Loan
Credit Union Other
Transit/ABA Number
City State Zip Code
Checking
Saving
Amount $
%
Account Number
Do you designate this account for direct deposit for Travel Reimbursement? Yes No
This
form must be received in the Human Resources Office by the 15
th
of the month in order to be effective on the
subsequent payroll. If you change bank accounts and/or financial institutions, a new authorization form must be
submitted. This authorization will remain in effect until you provide written notification to cancel. A
voided check
or deposit slip MUST be submitted for each account listed above. If you cannot furnish a voided check or deposit
slip, please have your financial institution complete the financial information section of this form and sign in the
appropriate box below.
Employee Signature
Department
Employee Name Fa
culty/Staff
Student
Employee ID:
Bank Representative Signature
Date
___________________
For your protection, this completed form must be returned to the Human Resources Office
in person. We cannot accept forms submitted via Campus Mail or by email.
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Direct Deposit Form-revised-050719 3

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Completed 3 July 2020

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