DIRECT DEPOSIT WAIVER REQUEST EMPLOYEE NAME DEPARTMENT/ EMPLOYEE SSN EMPLOYEE ADDRESS: (STREET/CITY/STATE/ZIP) 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): I ... 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.
Allowed
Adobe Portable Document Format (.pdf) - application/pdf
LCTCS Direct Deposit Waiver Form as of 11-19-15.pdf
DELGADO FORMS 
