Direct Deposit Authorization Form
Authorization Agreement for Direct Deposit Refunds
By signing this form, I agree to the following terms
and authorize my refunds to be deposited directly to my
checking account at the financial institution shown below:
I confirm that this bank account belongs to me. Joint accounts ar
e accepted as long as your name appears on the check or bank
statement.
I
confirm
that this bank account is a checking account.
This request will remain in effect until I have made a written request to stop or change my Direct Deposit.
It is my responsibility to notify the Student Accounts Office of any changes or closed accounts at least 6 business days prior to
my next refund.
I authorize George Mason University to initiate any credit and debit adjustments to my student account for refunds processed in
error.
Will any portion of this refund be transferred to a foreign financial instituiton? Yes
No
____________________________________
Student Signature Date
Please visit the following link for instructions on how to upload the Direct Deposit Form securely to the Mason Student
Services Center. http://studentaccounts.gmu.edu/wp-content/uploads/DirectDepositGuide.pdf
Student Accounts Office
4400 University Drive, MS 2E2, Fairfax, Virginia 22030
Phone: 703-993-2484
By signing this form, I confirm that the information that I provided is accurate. I understand that
providing incorrect direct deposit information will delay my refund by up to 60 days.
Bank Name:
Bank Transit Routing Number (ABA):
(Note -this must be 9 digits)
Bank Account Number:
Name on Account:
Banking Information
Information must be clear and legible. If not, the form will not be processed and a refund check will be sent.
Student ID: G
Date:
- -
Student Name: _____________________________________________________________
Last
First
M.I.
Daytime Telephone Number: __________________________________________________________________________
click to sign
signature
click to edit
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