DIRECT DEPOSIT WAIVER REQUEST
EMPLOYEE NAME
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DEPARTMENT/ EMPLOYEE SSN |
EMPLOYEE ADDRESS: (STREET/CITY/STATE/ZIP)
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WAIVER STATEMENT |
I, ________________________________________ (print full name), hereby request waiver of the requirement for direct deposit of my future paychecks for the following reason:
Geographical Barrier Physical/Mental Disability Barrier
Unable to establish account Other
PLEASE USE THIS SPACE TO EXPLAIN THE ABOVE INDICATED REASON (indicate if supporting documentation is attached):
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I understand that if my request for waiver of the payroll direct deposit requirement is approved, my paycheck will be delivered to my department head for pick up on payday Friday. If this request is denied, I understand that my paycheck will be held and I will not receive payment until I submit a completed direct deposit enrollment authorization form to the Payroll Manager.
_____________________________________ ______________________ ________________________________
Signature Date Daytime Phone between 8 am and 4:30 pm
CONTROLLER’S OFFICE USE ONLY |
I hereby certify that the above reasons and/or supporting documentation meet the requirement for granting a waiver.
APPROVED DENIED ________________________________________ ______________
Assistant Vice Chancellor/ Controller’s Signature Date
Copies to : Payroll Office, Employee; Original: Employee’s Personnel File
Form BAA-K01/002 (2/09)