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Direct Deposit Waiver Request Form (LCTCS Form)
Form used to request waiver of biweekly direct deposit of net pay.
Handle: Document-3586
Owner: Laiche, Karen (User-23, klaich:DocuShare)DS
Thursday, February 19, 2009 11:21:26 AM CST
Thursday, November 19, 2015 03:06:50 PM CST
Modified By: Laiche, Karen (User-23, klaich:DocuShare)DS
Locked By:
  • 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.
Adobe Portable Document Format (.pdf) - application/pdf
LCTCS Direct Deposit Waiver Form as of 11-19-15.pdf
Appears In: ALL FORMS - Alphabetically Listed by Form Title DELGADO FORMS HUMAN RESOURCES FORMS
Preferred Version: Direct Deposit Waiver Request Form (Form BAA-K01/002)