Topeka Public Schools 624 SW 24th St • Topeka, KS 66611 Phone: (785) 295-3069 • Fax: (785) 575-6169 Website: www.topekapublicschools.net

Direct Deposit/Pay Card Authorization

Reset Form

Please Print • See reverse side for instructions. SECTION A - PERSONAL INFORMATION Social Security Number Name (last/first/middle) Employee Classification Administrator

Certified

Classified

Substitute

Retiree

ARE YOU CHANGING ANY OF YOUR CONTACT INFORMATION? It is important that Topeka Public Schools maintain your current contact information. If your contact information has not changed, check no and skip to Section B. If your contact information has changed, check yes and provide us with the updated information.

No

My mailing address, phone numbers and email address are staying the same, SKIP TO SECTION B New Mailing Address (PO or street/city/zip)

Yes

New Work Phone Number New Primary Phone Number (home/cell)

SECTION B - CHOOSE DIRECT DEPOSIT OR REQUEST A PAY CARD Deposit Into Existing Account Please select to have your paycheck deposited to one or multiple accounts. Fill out if you have a current account or active pay card with routing number for direct deposit. When adding additional accounts, you must fill out the section on the right even if you have an account on file.

To direct deposit into a bank account(s): attach a voided check or deposit slip for verification needed to electronically transfer your paycheck into your account. A sample check and deposit slip on the back of this form show you where to locate the numbers you will need. For deposits to an active pay card: attach account verification including the routing and account number.

Name of Bank/Financial Institution Routing Number (ABA) Number Account Number Account Type Net Deposit

Checking (attach voided check)

Savings (attach deposit slip)

Pay Card

Savings (attach deposit slip)

Pay Card

Set Dollar Amount $

Name of Bank/Financial Institution Routing Number (ABA) Number Account Number

-ORRequest a New Pay Card Select only if you do not have an account in which to deposit funds.

Account Type Net Deposit

Checking (attach voided check)

Set Dollar Amount $

Any employee may participate in the CoreFirst pay card program as an alternative to direct deposit. The rules and applicable fees are in the terms and conditions provided by the pay card merchant. By signing below, you agree to abide by the cardholders’ terms and conditions.

SECTION C - APPLICANT SIGNATURE This authority is to remain in full force and effect until USD #501 has received written notification from me (or my beneficiary) of its termination in such time and such manner as to afford USD #501, Financial Institution, and Bank a reasonable opportunity to act on it. I do hereby authorize Topeka Public Schools to either: deposite my payroll check directly into my Checking or Savings accounts as specified on this form, load to my active pay card, or to the CoreFirst pay card issed to me by Topeka Public Schools. I understand this authorization will remain in effect until I provide timely written notice to change this service. I also understand that my account may recieve a prenote transaction one pay cycle before I can begin the direct deposit on a live basis.

Signature

Date

Instructions for Completing

Direct Deposit/Pay Card Authorization The standard method of receiving payroll checks is direct deposit. This completed authorization form allows TPS to electronically transfer your payroll into your checking or savings account each payday. The authorization must be signed, dated, and returned to TPS. Steps to complete the authorization are outlined below. 1. Complete Section A. • Employee must appropriately designate to what account(s) their pay check will go. If going to multiple accounts, please specify a set dollar amount for one account, and which account will receive the net deposit (remainder of the check). • A voided check or a Savings account deposit slip must be attached to process request. • An incomplete or altered authorization form will not be accepted. • It is important that Topeka Public Schools maintain your current contact information. If your address, phone numbers or email address has or will soon change, please update this section, otherwise skip to section B. 2. In Section B, choose an account(s) for direct deposit or request a pay card. You will pick up your pay card the payday following the application date in the Payroll department. 3. Sign and date Section C. • This form must be signed by the Topeka Public Schools employee. 4. Return complete form to Payroll in the Burnett Center. Include a voided check or deposit slip for direct deposits to checking or savings account. •

If you change accounts or financial institutions you must complete and submit a new Direct Deposit/Pay Card Authorization form. Keep in mind that if your direct deposit account is closed too soon, the financial institution will return your direct deposit to Topeka Public Schools, causing your payment to be delayed. Therefore, keep your initial direct deposit account open until you make a change.

Account Type - Checking (attach voided check)

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1 - 9-Digit Bank Routing Number



2 - Account Number



3 - Check Number



Account Type - Savings

TO BE USED FOR DEPOSIT TRANSACTIONS ONLY

(attach deposit slip)

1 - 9-Digit Bank Routing Number



2 - Account Number 3 - Your bank may use different routing numbers for deposits. If your deposit slip has this notation, use this routing number for your direct deposit.

SIGN HERE IF RECEIVING CASH

ACCOUNT ROUTING NUMBER: 222222234

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