Office of the University Controller
Florida State University
FORM PURPOSE: To start, change or stop direct deposit for vendor payments received from Florida State University. Vendors may deposit to only
one checking account. Please fill in all fields, with the exception of the OMNI Vendor #.
Direct Deposit Action (check one) :
Vendor E.I.N
OMNI Vendor # (FSU Use)
Company Name Daytime Phone Number
Start Change Stop
Checking Account Number
Transit/Routing Number
Name of Financial Institution
Financial Institution Phone #
SPECIAL NOTE: Please make sure your direct deposit has stopped before closing your account. Otherwise, the funds will be returned to FSU and
cause a seven to ten-day delay before you receive your payment. Direct deposits take effect immediately, so please ensure your information is
correct. FSU is not liable for any incorrect information submitted by the vendor on this form (e.g., account number, routing number, vendor
identification number).
I, the undersigned, hereby authorize and request Florida State University to initiate credit entries and, if necessary,
a debit entry in accordance with NACHA rules reversing a credit entry made in error, to my account at the above-named financial institution.
This direct deposit is to remain in effect until changed by: (a) an officer of the vendor; (b) the vendor's legal representative; (c) the above-named
financial institution; or (d) The Florida State University. Any change must be in writing and must be transmitted in a timely manner for any
change to take effect. This election will remain in effect until the option is cancelled. The authorized signature below signifies acceptance of the
terms and conditions stated above.
____________________________________________
Signature :
Date
VENDOR DIRECT DEPOSIT AUTHORIZATION
(Please be sure to confirm the below information with your Financial Institution)
Payables and Disbursements
5607 University Center A
Tallahassee, FL 32306-2391
Ph: (850) 644-5021 Fax: (850) 644-8137
PA-1
(Revised 05/2016)
Remittance Email:
Remittance Email 2:
(where remittance emails will be sent)
(optional - remittance emails can be sent to multiple addresses)
