Louisiana Delta Community College
Direct Deposit - Payment Delivery
Autho
r
i
z
ation
Please print or
ty
pe
Name:
(As it appears on W-9)
Email Add
re
ss
:
(For Direct Deposit Advice)
I authorize the Louisiana Delta Community College to initiate electronic credit entries to the account I
have indicated below for all non-payroll related payments due to me.
For any funds paid to me which are not due and owing to me, through direct deposit, I hereby agree and
authorize LDCC to initiate compensating electronic transactions to reverse any over or incorrect
payments. In the event such electronic transactions are unsuccessful, LDCC will notify me of the amount
to be returned.
I acknowledge that the origination of ACH transactions to my account must comply with the provisions
of Louisiana and U.S. law.
Financial Institution Name
Financial Institution Routing (ABA) Number
Checking Savin
g
s
Bank Account Change
Update Mailing Address
Add
re
ss Lin
e
1
Add
re
ss Lin
e
2
Cit
y,
Sta
te
P
os
t
al Cod
e
SIGNATURE Date
(Signature of Bank Account Authorized Signer)
click to sign
signature
click to edit
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