Fillable Payment Authorization Form (Ferris State University)

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Payment Authorization Form (Ferris State University)

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Country of origin: US
File type: PDF

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1. Check the box on the left for each account you would like.
2. Fill in the account information and the deduction amount. For each account,
you may select a dollar amount, percentage, or the balance to be deposited.
If Choosing Direct Deposit:
Please attach a voided check or copy of
check here. Do not attach a deposit slip,
the routing number is not always correct.
First Name: Last Name:
Phone Number:
Email Address:
Employee ID Number:
Date of Birth:
Signature: Date:
Direct Deposit
Focus Pay Card
By choosing traditional direct deposit, your pay will be deposited directly into your checking or
savings account each payday. Direct Deposit becomes
effective the second paycheck
after
this form is received by the Payroll FSU Office.
With the Focus Card, your pay will be deposited onto a prepaid Vis
a®
c
ard. Your card can be used anywhere Visa debit cards are accepted
worldwide. It’s not a credit car
d and there is no cost to enroll.
Bank Name Account # Routing #
Type Of
Account
Deduction Amount
I understand that if my account(s) at the financial institution(s) listed above has
been changed or closed, I must
inform the FSU Payroll Office in writing. FSU is unable to refund rejected monies until they are credited to
the FSU Payroll Account.
I would like to receive printed pay stub copies.
NOTE: Pay stubs are available to access on MyFSU. For instructions on accessing your paystub via
MyFSU, go to ferris.edu/payroll and click on "Viewing Pay Stub Instructions"
The Focus Card is issued by U.S. Bank National Association pursuant to a license from Visa U.S.A. Inc. Member FDIC. © 2014 U.S. Bank. REVISED July 1, 2019
USB-380-12 Focus Mult Auth Form_v3_LR.indd 1 3/17/14 3:14 PM
Account Information
Two Convenient Options
Employee Information
Payment Authorization Form
Important Information About Procedures For Opening A New Account
To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and
record information that identifies each person who opens an account. What this means for you: when you open an account, we will ask for your name,
address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.
I hereby authorize my employer to initiate credit entries (deposits) and to initiate, if necessary, debit entries and adjustments for any credit entries in
error to my Focus Card or bank account. This authorization will remain in effect until canceled by me with written notification to my employer.
Checking
Savings
$_______.00
%
R
emaining balance
Checking
Savings
$_______.00
%
Remaining balance
Checking
Savings
U.S. Bank
Focus Card
N/A N/A Focus Card
$_______.0
0
%
Remaining balance
Checking
Savings
$_______.00
%
Remaining balance
New
Change
Stop
New
Change
Stop
New
Change
Stop
New
Change
Stop
New
Change
Stop
$_______.0
0
%
Remaining balance
click to sign
signature
click to edit
CR-16616998
U.S. Bank Focus Card™ Pre-Acquisition Disclosure
Program Number: 151529210
Reference Date: July 2018
You have options as to how you receive your payments,
including direct deposit to your bank account or this prepaid card.
Ask your employer for available options and select your option.
Monthly fee
$0
Per purchase
$0
ATM withdrawal
$0 in-network
$2.00 out-of-network
Cash reload
$5.95*
ATM Balance Inquiry (in-network or out-of-network)
$0 or $1.00
Customer Service (automated or live agent)
$0 per call
Inactivity
(after 90 days with no transactions)
$2.00*
per month
We charge 4 other types of fees. One of them is:
International Transaction
3%*
*This fee can be lower or charged differently depending on how and where this card is used and your
state of employment or residence.
See the accompanying Fee Schedule for free ways to access your funds and balance information.
N
o overdraft/credit feature.
Your funds are eligible for FDIC insurance.
F
or general information about prepaid accounts, visit cfpb.gov/prepaid.
Find details and conditions for all fees and services inside the card package or call
1-877-474-0010 or visit usbankfocus.com
.
The Focus Card is issued by U.S. Bank National Association pursuant to a license from Visa U.S.A. Inc. © 2018 U.S. Bank. Member FDIC.
CR-16616998
U.S. Bank Focus Card™ Fee Schedule
Program Number: 151529210
Effective Date: July 2018
All fees
Amount
Details
Add money
Check Reload 5% or
$5.00 min.
This is not our fee and is subject to change. Fee of up to 5% of
check value may apply when cashing a check to load your c
ard at
Ingo Money. Money in Minutes - 2% (pre-printed payroll or gov't
checks) or 5% (all other checks), minimum $5.00. Money in 10
Days - no fee. Fee is deducted from check value. Go to
ingomoney.com for more information.
Cash Reload –
Visa Readylink
Varies by
retailer
Third party fee may apply when reloading your card at a Visa
Readylink network. Fee is paid to third party at the time of reload.
Go to usa.visa.com/pay-with-visa/cards/services-locator.html for
locations.
Cash Reload –
GreenDot
$5.95 This is not our fee and is subject to change. Fee of up to $5.95
may apply when reloading your card at GreenDot
®
. Fee is paid to
third party at the time of reload. Go to greendot.com for more
information.
Get cash
ATM Withdrawal
(in-network)
$0 This is our fee per withdrawal. “In-network” refers to the U.S.
Bank
or MoneyPass
®
or Allpoint
®
ATM networks. Locations can be
found at usbank.com/locations or moneypass.com/atm-locator or
allpointnetwork.com. Your employer has designated certain on-
site ATMs as being in-network. Contact your HR representative
for information on which ATMs have been so designated.
ATM Withdrawal
(out-of-network)
$2.00 This is our fee per withdrawal. “Out-of-network” refers to all the
ATMs outside of the U.S. Bank or MoneyPass or Allpoint ATM
networks. You may also be charged a fee by the ATM operator
even if you do not complete a transaction.
Teller Cash
Withdrawal
$0 This is our fee for when you withdraw cash from your card from a
teller at a bank or credit union that accepts Visa
®
.
Information
ATM Balance
Inquiry (in-
network)
$0 This is our fee per inquiry. “In-network” refers to the U.S. Bank or
MoneyPass or Allpoint ATM networks. Locations can be found at
usbank.com/locations or moneypass.com/atm-locator or
allpointnetwork.com. Your employer has designated certain on-
site ATMs as being in-network. Contact your HR representative
for information on which ATMs have been so designated.
ATM Balance
Inquiry (out-of-
network)
$1.00 This is our fee per inquiry. “Out-of-network” refers to all the ATMs
outside of the U.S. Bank or MoneyPass or Allpoint ATM n
etworks.
You may also be charged a fee by the ATM operator.
The Focus Card is issued by U.S. Bank National Association pursuant to a license from Visa U.S.A. Inc. © 2018 U.S. Bank. Member FDIC.
CR-16616998
Using your card outside the U.S.
International
Transaction
3% This is our fee which applies when you use your card for
purchases at foreign merchants and for cash withdrawals from
foreign ATMs and is a percentage of the transaction dollar
amount, after any currency conversion. Some merchant and ATM
transactions, even if you and/or the merchant or ATM are located
in the United States, are considered foreign transactions under
the applicable network rules, and we do not control how these
merchants, ATMs and transactions are classified for this purpose.
For Connecticut, Illinois and Pennsylvania workers, all
international purchase fees are waived.
International ATM
Withdrawal
$3.00 This is our fee per withdrawal. You may also be charged a fee by
the ATM operator even if you do not complete a transaction.
International ATM
Balance Inquiry
$1.00 This is our fee per inquiry. You may also be charged a fee by the
ATM operator.
Other
Card
Replacement
$5.00 This is our fee per replacement of your card, whether mailed to
you with standard delivery (up to 10 business days)
or provided to
you by your employer/sponsor. This fee is waived for your first
card replacement in a 12-month period. This fee will be charged
for each additional replacement during the same 12 months. For
Connecticut, Hawaii and Pennsylvania workers, this fee is waived.
Card
Replacement
Expedited
Delivery
$10.00 This is our fee for expedited delivery (up to 3 business days)
charged in addition to any Card Replacement fee.
Card
Replacement
Overnight
Delivery
$20.00 This is our fee for overnight delivery charged in addition to any
Card Replacement fee.
Inactivity
$2.00
This is our fee charged each month after you have not completed
a transaction using your card for 90 consecutive days. For
Connecticut, Illinois, and Pennsylvania workers, this fee will be
waived for the first 12 months of inactivity (based on cardholder-
initiated balance changing transactions).
For Texas residents, this
fee will not be charged after one year of inactivity. For Minnesota
and Montana workers this fee is waived. For Hawaii workers,
accounts with a balance of $0.00 and no activity for more than 6
months may be closed.
Your funds are eligible for FDIC insurance up to $250,000. FDIC insurance protects deposits from loss due to bank insolvency. See
fdic.gov/deposit/deposits/prepaid.html
for details.
No overdraft/credit feature.
Contact Cardholder Services by calling 1-877-474-0010, by mail at P.O. Box 551617, Jacksonville, FL 32255 or visit usbankfocus.com.
For general information about prepaid accounts, visit cfpb.gov/prepaid. If you have a complaint about a prepaid account, call the Consumer Financial
Protection Bureau at 1-855-411-2372 or visit cfpb.gov/complaint.
Important information: Fee waivers for workers of a particular state are applied based on information from the sponsoring employer regarding your state
of employment.
CR-16653603
Divulgación Previa a la Adquisición de la Tarjeta U.S. Bank Focus™
Número de Programa: 151529210
Fecha de Referencia: julio de 2018
Usted tiene opciones con respecto a cómo recibir sus pagos,
incluidos el depósito directo en su cuenta de banco o esta tarjeta prepagada.
Consulte a su empleador sobre las opciones disponibles y seleccione su opción.
Cargo
mensual
$0
Por compra
$0
Retiro de fondos en ATM
$0 dentro de la red
$2.00 fuera de la red
Recarga de
efectivo
$5.95*
Consulta de Saldo en ATM (dentro o fuera de la red)
$0 o $1.00
Servicio al Cliente (automatizado o representante en vivo)
$0 por llamada
Inactividad
(después de 90 días sin transacciones)
$2.00*
por mes
Cobramos otros 4 tipos de cargos. Este es uno de ellos:
Transacción Internacional
3%*
*Este cargo puede ser menor o puede cobrarse de manera diferente, dependiendo de cómo y dónde
se utilice esta tarjeta y del estado en el que resida o trabaje.
Consulte la Lista de Cargos adjunta para saber cómo acceder de manera gratuita a la información de
sus fondos y saldos.
Sin prestación de sobregiro/crédito.
Sus fondos son elegibles para el seguro FDIC.
Para obtener información general sobre cuentas prepagadas, visite cfpb.gov/prepaid.
Encuentre detalles y condiciones de todos los cargos y servicios en el paquete de la tarjeta,
llame al 1-877-474-0010 o visite usbankfocus.com.
La Tarjeta Focus es emitida por U.S. Bank National Association, de conformidad con una licencia de Visa U.S.A Inc. © 2018 U.S. Bank. Miembro FDIC.
CR-16653603
Lista de Cargos de la Tarjeta U.S. Bank Focus™
Número de Programa: 151529210
Fecha de Vigencia: julio de 2018
Todos los
Monto
Detalles
Agregar dinero
Recarga con
Cheque
5% o mínimo
de $5.00
Este cargo no es nuestro y está sujeto a cambios. Se puede
aplicar un cargo de hasta el 5% del valor del cheque cuando
cobre un cheque para cargar su tarjeta en Ingo Money. Dinero en
Minutos: 2% (cheques preimpresos de nómina o de gobierno) o
5% (todos los demás cheques), mínimo de $5.00. Dinero en
10 Días: sin cargo. El cargo se deduce del valor del cheque.
Visite ingomoney.com para obtener más información.
Recarga de
Efectivo –
Visa Readylink
Varía según
el comercio
minorista
Es posible que se apliquen cargos de terceros cuando recargue
su tarjeta en una red Visa Readylink. Este cargo se paga a un
tercero en el momento de la recarga. Visite usa.visa.com/pay-
with-visa/cards/services-locator.html para encontrar ubicaciones.
Recarga de
Efectivo –
GreenDot
$5.95 Este cargo no es nuestro y está sujeto a cambios. Es posible que
se aplique un cargo de $5.95 cuando recargue su tarjeta en
GreenDot
®
. Este cargo se paga a un tercero en el momento de la
recarga. Visite greendot.com para obtener más información.
Retiro de efectivo
Retiro de Fondos
en ATM
(dentro de la red)
$0 Este es nuestro cargo por retiro de fondos. “Dentro de la red” se
refiere a las redes de ATM de U.S. Bank, MoneyPass
®
y
Allpoint
®
. Puede encontrar las ubicaciones en
usbank.com/locations, moneypass.com/atm-locator y
allpointnetwork.com. Su empleador ha designado algunos ATM
como dentro de la red. Contacte su representante de Recursos
Humanos para saber cuáles son los ATM designados.
Retiro de Fondos
en ATM
(fuera de la red)
$2.00 Este es nuestro cargo por retiro de fondos. “Fuera de la red” se
refiere a todos los ATM que se encuentran fuera de las redes de
ATM de U.S. Bank, MoneyPass y Allpoint. El operador del ATM
también puede cobrarle un cargo, incluso si no termina de
realizar la transacción.
Retiro de Fondos
en Efectivo
Asistido por
Personal Bancario
de Ventanilla
$0 Este es nuestro cargo por realizar un retiro de fondos en efectivo
desde su tarjeta con la ayuda del personal bancario de ventanilla
en un banco o cooperativa de crédito que acepte Visa
®
.
Información
La Tarjeta Focus es emitida por U.S. Bank National Association, de conformidad con una licencia de Visa U.S.A Inc. © 2018 U.S. Bank. Miembro FDIC.
CR-16653603
Consulta de Saldo
en ATM
(dentro de la red)
$0
Este es nuestro cargo por consulta. “Dentro de la red” se refiere a
las redes de ATM de U.S. Bank, MoneyPass y Allpoint. Puede
encontrar las ubicaciones en usbank.com/locations,
moneypass.com/atm-locator y allpointnetwork.com
. Su empleador
ha designado algunos ATM como dentro de la red. Contacte su
representante de Recursos Humanos para saber cuáles son los
ATM designados.
Consulta de Saldo
en ATM
(fuera de la red)
$1.00 Este es nuestro cargo por consulta. “Fuera de la red” se refiere a
todos los ATM que se encuentran fuera de las redes de ATM de
U.S. Bank, MoneyPass y Allpoint. El operador del ATM también
puede cobrarle un cargo.
Uso de su tarjeta fuera de los EE. UU.
Transacción
Internacional
3% Este es el cargo que cobramos y que se aplica al uso de su
tarjeta para compras en comercios extranjeros y por retiros de
fondos en efectivo en ATM extranjeros y es un porcentaje del
monto en dólares de la transacción después de cualquier
conversión de moneda. Algunos comercios y transacciones de
ATM, incluso aunque usted y el comercio o ATM estén ubicados
en los Estados Unidos, se consideran transacciones en el
extranjero conforme a las reglas aplicables de la red, y nosotros
no tenemos control sobre cómo se clasifican estos comercios,
ATM y transacciones para este fin. Los cargos de compra
internacional no se cobran a los trabajadores de Connecticut,
Illinois y Pennsylvania.
Retiro de Fondos
en ATM
Internacional
$3.00 Este es nuestro cargo por retiro de fondos. El operador del ATM
también puede cobrarle un cargo, incluso si no termina de
realizar la transacción.
Consulta de Saldo
en ATM
Internacional
$1.00 Este es nuestro cargo por consulta. El operador del ATM también
puede cobrarle un cargo.
Otros
Reemplazo de
Tarjeta
$5.00 Este es nuestro cargo por el reemplazo de su tarjeta, ya sea con
servicio de entrega estándar (hasta 10 días hábiles) o si se la
proporciona su empleador/patrocinador. No cobramos este cargo
por el primer reemplazo de su tarjeta en un período de 12 meses.
Este cargo se cobrará por cada reemplazo adicional durante los
mismos 12 meses. Este cargo no se cobra a los trabajadores de
Connecticut, Hawaii y Pennsylvania.
Reemplazo
de Tarjeta con
Entrega Expresa
$10.00 Este es nuestro cargo por entrega expresa (hasta 3 días hábiles),
adicionales a cualquier cargo por Reemplazo de Tarjeta.
La Tarjeta Focus es emitida por U.S. Bank National Association, de conformidad con una licencia de Visa U.S.A Inc. © 2018 U.S. Bank. Miembro FDIC.
CR-16653603
Reemplazo
de Tarjeta con
Envío al Día
Siguiente
$20.00 Este es nuestro cargo por envío al día siguiente, adicional a
cualquier cargo por Reemplazo de Tarjeta.
Inactividad
$2.00
Este es nuestro cargo por mes si no ha realizado una transacción
con su tarjeta durante 90 días consecutivos. Para los
trabajadores de Connecticut, Illinois y Pennsylvania, este cargo
no se cobrará por los primeros 12 meses de inactividad (de
acuerdo con transacciones iniciadas por el titular de tarjeta que
modifiquen el saldo). Para residentes de Texas, este cargo no se
cobrará después de un año de inactividad. Este cargo no se
cobra a los trabajadores de Minnesota y Montana. Para los
trabajadores de Hawaii, las cuentas que tengan un saldo de
$0.00 y que no tengan actividad durante más de 6 meses se
cerrarán.
Sus fondos son elegibles para el seguro FDIC hasta $250,000. El seguro FDIC protege los depósitos por pérdida debido a insolvencia bancaria.
Consulte fdic.gov/deposit/deposits/prepaid.html
para obtener detalles.
Sin prestación de sobregiro/crédito.
Comuníquese con Servicios para Titulares de Tarjetas, llamando al 1-877-474-0010, por correo a Cardholder Services P.O. Box 551617, Jacksonville,
FL 32255 o visite usbankfocus.com.
Para obtener información general sobre cuentas prepagadas, visite cfpb.gov/prepaid. Si tiene alguna queja sobre una cuenta prepagada, llame a la Oficina
para la Protección Financiera del Consumidor (Consumer Financial Protection Bureau) al 1-855-411-2372, o visite cfpb.gov/complaint.
Información importante: Las exenciones de cargos para empleados de un estado en particular se aplican según la información proporcionada por su
empleador patrocinador respecto al estado en el cual ha sido empleado.
Si bien esta comunicación de U.S. Bank está disponible en español, ello no implica que las comunicaciones futuras se proporcionarán en dicho idioma.
Algunos servicios y correspondencia, incluidos documentos importantes referidos a la apertura y mantenimiento de nuestros productos (como contratos
y estados de cuenta), ciertos números de teléfono, páginas web y demás comunicaciones por Internet, podrían estar disponibles solo en inglés. De ser
necesario, tenemos intérpretes independientes disponibles para ayudarlo.
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Payment Authorization Form (Ferris State University)

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Completed 20 August 2020

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