Jackson State UniversityThe Business Office
Payroll and Employee Reimbursement
Direct Deposit Form
Name
Address
City State Zip Code
PLEASE CHECK ALL THAT APPLY
New Application
Change of Financial Institution - Payroll Cancel Authorization
Please contact your financial institution if you need assistance with the following information.
Note that Direct Deposit Refunds can only be applied to accounts at domestic (U.S.) financial institutions.
Checking/ Money Market
Savings Account
(Attach a voided check below to verify account information)
(1) Jackson State University to deposit my funds via Direct Deposit,
(2) My financial institution to credit my account, and
(3) Jackson State University to initiate and my financial institution to make adjustments to my
account for any incorrect credits/payments which may occur.
I also understand that a new authorization form must be completed if I change my account, close my account, change financial
institutions, or cancel authorization. I also understand that all requests for change should be submitted to Jackson State
University at least 2 weeks in advance, to enable the University and financial institution(s) to process appropriate transactions.
Email Phone Number
Signature
Date
FOR EMPLOYEE REIMBURSEMENT
RETURN TO: JACKSON STATE UNIVERSITY
THE BUSINESS OFFICE, P. O. BOX 17159
JACKSON, MS 39217
I hereby authorize:
J# or SSN
Employees have the right to modify this authorization at anytime.
Print Name Title
FOR PAYROLL
RETURN TO: JACKSON STATE UNIVERSITY
OFFICE OF HUMAN RESOURCES, P. O. BOX 17028
JACKSON, MS 39217
Change of Financial Institution - Employee Reimbursement
Financial Institution
Payroll Primary Payroll Secondary
Employee Reimbursement
Accounts Payable
Routing Number (ABA)
Account Number
Savings Account
Checking/ Money Market
Savings Account
Checking/ Money Market
Amount to be Deposited
or Percentage
Remaining Balance
