University of West Florida
Direct Deposit Authorization Form
Please read and carefully follow instructions. Please be sure your name on this form matches the name on your Form W-
4 on file in the payroll office. Your direct deposit will not start if the name does not match.
Please be advised that this form will replace all previous Direct Deposit Authorization Forms on file. Please fill out in entirety.
Attach Voided Check(s) or bank documentation for verification purposes for each account that is new or being
changed. (Deposit Slips will not be accepted.)
When you attach a voided check or other bank document that verifies the bank routing and account number, we can start your direct deposit with the next
processing of payroll. Otherwise, we will process a pre-note to ensure that there are no problems with the routing or account number. During the pre-note
process you will receive a paper check.
Last Name _________________________ First Name ______________________ Middle Initial ________
UWF ID# _____________________ Work Phone (_____) _______________ Home Phone (______) _____________
Direct Deposit #1 (Check One) New Change No Change Stop
If chosing one direct deposit, check the “Full Deposit” box. Check the box “Checking” or “Savings” and
provide bank routing and account number. If choosing more than one direct deposit, check the “Fixed
Amount” box and enter the Fixed Amount of the first deposit of the first bank.
Full Deposit or Fixed Amount $ Account Type: Checking Savings
Bank Routing Number _________________________________ Account # ___________________________________
Name of Financial Institution __________________________________________________________________________
Direct Deposit #2 (Check One) New Change No Change Stop
If choosing 2 direct deposits, check the “Balance” box. Check the box “Checking” or “Savings” and
provide bank routing number and account number of the second bank. If choosing more than 2 direct
deposits, check the “Fixed Amount” box, enter the amount and check the box “Checking” or “Savings”.
Balance or Fixed Amount $___________________ Account Type: Checking Savings
Bank Routing Number ________________________________ Account # ______________________________
Name of Financial Institution __________________________________________________________________________
Direct Deposit #3 (Check One) New Change No Change Stop
If choosing 3 direct deposits, check the “Balance” box, check the box “Checking” or “Savings” and
provide bank rounting number and account number.
Balance Account Type: Checking Savings
Bank Routing Number _________________________________ Account # ___________________________________
Name of Financial Institution __________________________________________________________________________
If you receive reimbursement payments processed through Accounts Payable please indicate which account to use. If no selection is made
funds will be deposited to the same account as the balance of your payroll check.
Direct Deposit # 1 Direct Deposit # 2 Direct Deposit # 3
Signature ______________________________________________ Date ___________________
Agreement: My signature above authorizes and requests the University of West Florida (UWF) to initiate credit entries and, if necessary, debit entries in accordance with NACHA
rules reversing a credit entry made in error, to my account at the financial institution(s) named. This direct deposit is to remain in effect until withdrawn by (a) me in writing with
sufficient notice to UWF to allow adequate time to effect termination; (b) my death or legal incapacity; (c) the financial institution or (d) UWF. It will purge approximately six months
after my last wage payment.
Completed Direct Deposit Authorization forms can be faxed to Payroll at (850) 474-3053 or mailed to 11000 University Pkwy. Attn: Payroll
Bldg 20E Pensacola, FL 32514. You can also submit the form in person to Payroll located in Bldg 20E. If you have any questions please
call the Payroll Office at (850) 474-3051. Rev 5/2010
