MIDDLE TENNESSEE STATE UNIVERSITY
DIRECT DEPOSIT AUTHORIZATION FORM

Print , fill in blanks, attach a voided check  from the account, and mail to Human Resource Services, Sam H. Ingram Building, P.O. Box 35, Murfreesboro, TN 37132.  For questions related to Direct Deposit please call
615-898-2929.

** If you currently have a direct deposit and have closed the account, please print and complete the Direct Deposit Cancellation Form.

Your direct deposit should start within 14 days. You may have a total of two direct deposit accounts. They may be at the same bank or at different banks. The deposit may be a dollar amount or a percentage of your paycheck. Your direct deposit receipt will be sent via email on each payday.  If you do not have an email account a pay stub will be sent to your home department.

If you are a regular employee, your final check will NOT be a direct deposit.

I hereby request that my Middle Tennessee State University payroll check be deposited automatically to the account(s) indicated on the attached void check/deposit slip below. I also authorize Middle Tennessee State University to debit (withdraw) any money which was transferred by mistake.

EMPLOYMENT STATUS


(Please Check)
Regular Employee Student Employee

Hourly Employee Adjunct, GA, GTA Employee


Student/Hourly employees, please indicate department where your deposit stub should be sent

__________________________________________________________________________________

Print Name: ___________________________________________________

Signature: ___________________________________________________    Date:______________________

M Number: ____________________________   Home Phone Number:______________________

 
Direct Deposit #1:    ____________________________________________
                                                     Name of Financial Institution

Checking ____________% or $_________          Routing #  _________________________   Account #  _________________________

Savings ____________% or $__________           Routing #  _________________________   Account #  _________________________

 
Direct Deposit #2:    ____________________________________________
                                                     Name of Financial Institution

Checking ____________% or $_________          Routing #  _________________________   Account #  _________________________

Savings ____________% or $__________          Routing #  _________________________   Account #  _________________________

*** PLEASE ATTACH VOIDED CHECK FOR CHECKING ACCOUNT ***

*** PLEASE ATTACH VOIDED DEPOSIT SLIP FOR SAVINGS ACCOUNT ***