LCTCSPR05_Ed112013.DirectDepositMainBank
LCTCS PAYROLL DIRECT DEPOSIT ENROLLMENT AUTHORIZATION –
Main Bank (Primary Account)
Employee ID:________________________________ VPDI/Institution Code:_______________________
Action Type (one): _____ New _____ Change _____ Termination This Option
Check box if same as payroll account.
*Account Name:
(
Ex: Mr. & Mrs. J. Doe)
*Financial Institution:
*Routing/ABA Number:
*Account Number:
*Account Type
(
Checking or Savings)
Signature from Institution: Signature from Institution:
*Account Verification
_______________________________________ __________________________________________
NON-PAYROLL REIMBURSEMENTS
Phone Number: _________________________
Phone Number: ____________________________
*Account verification or completion of enrollment form by financial institution is required to assure the accuracy of account
data if no voided check or other documentation is provided.
I, _______________________________________________, authorize and request the Louisiana Community & Technical College to
initiate electronic deposits (payroll and non-payroll) to the account(s) at the financial institution I have designated above.
For any funds paid to me which are not due and owing to me, through a pre-note paper check or through direct deposit, I hereby agree
and authorize my appointing authority (employer) to adjust the amount next due to me to correct the overpayment, or to recover
amount overpaid by reducing my future payroll checks and/or non-payroll reimbursements so that the overpayment will be repaid or
recouped within a reasonable number of months (not to exceed 12 months). In the event such electronic transactions are
unsuccessful, LCTCS will notify me of the amount to be returned).
It is my responsibility to notify Human Resources, as appropriate, should any changes occur to the account(s) specified. Considering
all above conditions are met, this authorization remains in full effect until a written, signed notification to terminate, or another signed
form (LCTCSPR20) indicating termination of this option is received from me and the LCTCS payroll department has had reasonable
opportunity to act on the termination.
_________________________________________ __________________ ________________________________
Signature Date Phone where you can be reached between 8:00 a.m.
and 5:00 p.m.
*Institution requirements may vary. Contact your human resources representative if you have any questions.
____ CHECK HERE IF SECONDARY ACCOUNT FORMS ARE ATTACHED.
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