Employee
?
ID:
?
_____________________________________
?
VPDI/Institution
?
Code:
?
SOWELA
??
Action?Type
?
(one):
?
? ?
_____ New
?
____ Change
?
____ Termination
?
This
?
Option
?
? PAYROLL %CHECK% o?NON-PAYROLL ?REIMBURSEMENTS?
Check ?box ?if ?same ?as ?payroll ?account.?
*Account ?Name:? ?
(Ex: ?Mr. ?& ?M rs. ?J. ?D oe ) ?
?
*Financial ?Institution:? ? ?
*Routing/ABA ?Num ber:? ? ?
*Account ?Number:? ? ?
*Account ?Type? ? ?
(Check ?or?Sav ing s)?
*Account ?Verification ? Signature?from ?Institution:? Signature?from ?Institution:?
? ?
_______________________________
?
_______________________________
?
Phone?Number:
?
__________________
?
Phone?Number:
?
__________________
?
____________________________________ _____________ ________________________________
LCTCSPRO5_Ed112013 .DirectDepositMainBank
LCTCS %PAYROLL%DIREC T %DEP OSIT %ENR OLLM E NT %AU TH OR IZATION %– %
Main %Bank %(Primary %Account)%
*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 initiation 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 pa
per 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 Ph
one 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 SECOND ARY%ACCOUN T%FORMS ARE ATTAC HED.
click to sign
signature
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click to sign
signature
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click to sign
signature
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