AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT OF REIMBURSEMENT

The University of Texas Health Science Center at Houston
AUTHORIZATION AGREEMENT FOR DIRECT
DEPOSIT OF REIMBURSEMENT

New Enrollment Change Discontinue

Employee Name:
(First, MI, Last) SSN#: - -
Vendor Code (if known):

Are you presently enrolled in Direct Deposit of Payroll? Yes No

You must send a voided check for verification of bank account information and complete the information requested below:

Depository Name
Bank Savings and Loans Credit Union
City State Zip
Transit/ ABA Number
Bank Account Number Checking Account Savings Account

I authorize The University of Texas Health Science Center at Houston to credit my account with the depository named above. If The University of Texas Health Science Center at Houston erroneously deposits funds into my account, I authorize the necessary debit entries not to exceed the total of the original amount credited.

The authorization will remain in effect until The University of Texas Health Science Center at Houston has received written notification from me that it is to be discontinued in such time and manner for the University to act on it.

Name:
Departmental Address
Telephone (Office) : ( ) -
Signature Date / /
E-MAIL ADDRESS:
(Required for automated notification)

Questions?
Call the FAST Team at 500-4949

University of Texas - Houston Health Science Center. Fast Team. UCT 901. 500-4949

Employee Name:	(First, MI, Last)	SSN#:	- -
Vendor Code (if known):

Depository Name	Bank Savings and Loans Credit Union
City	State Zip
Transit/ ABA Number
Bank Account Number	Checking Account Savings Account

Name:
Departmental Address
Telephone (Office) :	( ) -
Signature	Date / /
E-MAIL ADDRESS: (Required for automated notification)