UNIVERSITY OF WYOMING Payroll Authorization

UNIVERSITY OF WYOMING

Direct Deposit

DIRECT DEPOSIT AUTHORIZATION

Please complete the form by providing the appropriate information and attaching a voided check, account card,

or bank letter verifying the correct routing number and account number. The form MUST be signed in the

presence of either a University of Wyoming department representative OR a notary public.

* If a voided check is unavailable, please ensure the document provided (deposit slip, photocopy of account card, etc.)

includes the correct routing and account number. If necessary, contact your financial institution for this information.

For example, Wells Fargo, US Bank, Bank of the West and others DO NOT have the correct routing number on deposit

slips. A voided check is needed to obtain the correct routing number.

NAME ______________________________________________ SSN _________________________________

EMPLOYEE ID NUMBER ________________________________

Select one: ☐ NEW Agreement ☐ CHANGE of Agreement ☐ CANCEL Agreement

Name of Bank _______________________________________________

Routing Number _____________________________________________

Account Number_____________________________________________

Deposit Start Date____________________________________________

I have read and understand this form and the information provided is accurate. I understand that in signing this form, I

authorize the University of Wyoming to issue payment to the specified account until the University of Wyoming receives

written notice from me to change or cancel this agreement.

SIGNATURE ________________________________________________ DATE ______________________

I hereby certify that on this date, the above-named individual appeared before me and signed this document in my presence.

__________________________________________________________ ____________________

UW Department Representative OR Notary Public (if UW rep not available) DATE

Select one:

☐ Checking ☐ Savings

-- VOID --

-- Affix check here with TAPE -- Affix check here with TAPE -- Affix check here with TAPE