Jackson State UniversityThe Business Office
Vendor Direct Deposit
Authorization Form
Vendor's Name
Address
City State Zip Code
PLEASE CHECK ALL THAT APPLY
New Application Change of Financial Institution Cancel Authorization
Please contact your financial institution if you need assistance with the following information.
Note that Direct Deposit Refunds can only be applied to accounts at domestic (U.S.) financial institutions.
TYPE OF ACCOUNT - PLEASE CHECK ONE:
Checking or Money Market Account
Savings Account
(Attach a voided check below to verify account information)
(1) Jackson State University to deposit my funds via Direct Deposit,
(2) My financial institution to credit my account, and
(3) Jackson State University to initiate and my financial institution to make adjustments to my
account for any incorrect credits/payments which may occur.
This authorization will remain in effect until cancelled in writing. A new authorization must be completed if I change my
account, close my account, or change financial institutions. All requests for changes should be submitted to Jackson State
University at least 2 weeks in advance, to enable the University and financial institution(s) to process appropriate
transactions.
Email Phone Number
Signature Date
TRANSIT ROUTING (ABA)
NUMBER
ACCOUNT NUMBER
RETURN TO: JACKSON STATE UNIVERSITY
THE BUSINESS OFFICE, P. O. BOX 17250
JACKSON, MS 39217
I hereby authorize:
TIN Number
Bank Name StateCity
The vendor has the right to modify or rescind this authorization at anytime.
Contact Name
Print Name Title
