Lawrence University

AUTHORIZATION AGREEMENT FOR AUTOMATIC PAYROLL DEPOSITS

Employee Full Name _______________________________ LU ID # ___________________

(Print)

I hereby authorize Lawrence University to initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit entries in error to my checking and/or saving account(s) indicated below and the depository named below, to credit and/or debit the same to such account.

I understand that my payroll may have up to three direct deposits of my choice (i.e., 2 savings and 1 checking, 2 checking and 1 savings, or 3 checking). A full direct deposit means that the net pay will be deposited into one account. A partial direct deposit means that a specific amount per payroll check becomes a payroll deduction.

Deposit #1	Deposit #2	Deposit #3
___ New ___ Change ___ Cancel	___ New ___ Change ___ Cancel	___ New ___ Change ___ Cancel
Bank Name	Bank Name	Bank Name
Bank Routing #	Bank Routing #	Bank Routing #
Bank Account #	Bank Account #	Bank Account #
__________ Savings __________ Checking	__________ Savings __________ Checking	__________ Savings __________ Checking
Full Deposit – _____ Yes _____No	Remainder of Balance – _____ Yes _____No	Remainder of Balance – _____ Yes _____No
Per Payday Partial Amount: $	Per Payday Partial Amount: $	Per Payday Partial Amount: $

This authority is to remain in full force and effect until Lawrence University has received written notification from me of its termination in such time and such manner as to afford Lawrence University and depository a reasonable opportunity to act on it.

Authorization Signature: _________________________________ Date: _________________

NOTE: A voided check must be attached for checking accounts.

Documentation of routing and account numbers must be attached for savings accounts.

Please read Direct Deposit Fact Sheet for more information.