Direct Deposit Authorization

Please complete this form and return it to the payroll department. Be sure to include a voided check from your checking account and/or a deposit slip for your savings account, whichever is applicable. Under this program, you have the option (if you so choose) to deposit a portion of your net pay into a secondary account, such as savings or credit union account.

Name:	Your Financial Institution:
Social Security Number:	City/State

Primary Account Number Please circle the one that applies: Checking Savings Pay Card

Secondary Account Number Dollar Amount $ Please circle the one that applies: Checking Savings

I authorize Augusta State University and the above Financial Institution to deposit my net pay and/or flat amount automatically into my account(s) each pay day, and to initiate adjustments, if necessary, for any entries made in error to my account.

(Signature) (Date)

Attach Voided Check(s) Here