University Of Alaska
Direct Deposit Request Form
Please Read: Complete, sign, and date this form in blue or black ink to begin, change, or stop the direct deposit of
and requested back-up documentationyour bi-weekly university pay. Return the original completed form to your
campus Payroll office.
Conditions of Direct Deposit:
If
you are starting or changing your direct deposit, allow at least 2 pay periods for processing. See page 2 for
further instructions. Your university pay can be deposited to any participating U.S. bank, credit union, or savings &
loan. Brokerage, money market, or check card accounts are not eligible. You may split your deposit between a
maximum of two accounts (at the same or separate financial institutions). Always verify the net deposit amount on
your pay stub with your financial institution or account statement. If making a change to accounts, do not close an
account until you verify that account changes have been made. If terminating from the University of Alaska, do not
close an account until you verify that your final university pay has been received. Upon termination of your
employment with the University of Alaska, your direct deposit will be inactivated. Your pay stub can be viewed on
UAOnline at http://www.uaonline.alaska.edu. UA does not print auto deposit stubs for employees, unless the
employee submits an Auto deposit Paystub Option Form. More information is available at
http://www.alaska.edu/hr/hr-procedures/employeeprocedures/payroll/autodeposit-information/.
I hereby authorize the University of Alaska to deposit my bi-weekly net pay to the financial institution(s) and
account(s) noted above. I understand that the University of Alaska has the right to reverse any deposit made to my
account(s) in error. I also understand that the University of Alaska may substitute a payroll check in place of my
direct deposit if necessary. I understand that efforts will be made to notify me of any problems with my direct
deposit in a timely manner.
Please note that the account and/or routing number for direct deposit may not be the account and/or routing number
l
isted on your personal deposit slip.
Employee Signature: _______________________________________ Date: ______________________
To be completed by campus Payroll office:
Entered by: ____________________________ Effective Date or Run #: ___________________________
Deposit # 1 Deposit # 2 Please Print Legibly
Action: (check one)
Start _____
Change _____ Stop _____
Account Closed?:
Yes _____ No _____
Financial Institution Name:
_________________________________________
Phone # : ________________________________
Routing # : __
__ __ __ __ __ __ __ __
Account Type: (check one)
Checking
_____ Savings _
Account # :______________________________
____
Deposit Amount:
$__________________ OR
_________________
_ % of Net Pay
Action:
(check one)
Start
_____ Change _____ Stop _____
Account Closed?: Yes _____ No
_____
Financial Institution Name:
_________________________________________
Phone #
: _________________________________
Routing # : __
__ __ __ __ __ __ __ __
Account Type: (check one)
Checking
_____ Savings _____
Account # : _______________________________
Deposit Amount:
$_ OR _________________
All Remaining Pay
OR __________________ % of Remaining Net Pay
Note: Your name must be listed on the bank account. Also, the account/routing number for direct deposit
may differ from the account/routing number listed on your personal deposit slip.
Office Use Only: Office Use Only:
Priority of Deposit # 1: Priority of Deposit # 2:
Status: Pre-note Active Inactive Status: Pre-note Active Inactive
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signature
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