Financial Administrative Support —the FAS Team
... DD Form Example 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) Employee ID#: Vendor Code (if known): Student ID#: 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 AK AL AR AZ CA CO CT DC DE FC FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN N/A TX UT VA VI VT WA WI WV WY Zip Transit/ABA # Bank Account # 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 FAS Team at 713-500-4949 Please print and return completed form to: University of Texas Health Science Center at Houston. FAS Team. UCT 901. 713-500-4949. The University of Texas Health Science Center at Houston Site maintained by Finance Last updated January 30, 2009
... DD Form Example
New Enrollment Change Discontinue
Employee Name:
(First, MI, Last)
Employee ID#:
Vendor Code (if known):
Student ID#:
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 AK AL AR AZ CA CO CT DC DE FC FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN N/A TX UT VA VI VT WA WI WV WY Zip
Transit/ABA #
Bank Account #
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 FAS Team at 713-500-4949 Please print and return completed form to:
University of Texas Health Science Center at Houston. FAS Team. UCT 901. 713-500-4949.
The University of Texas Health Science Center at Houston Site maintained by Finance Last updated January 30, 2009
... DD Form Example
