UNIVERSITY OF UTAH INCOME ACCOUNTING & STUDENT LOAN SERVICES 201 SOUTH 1460 EAST, ROOM 165 TELEPHONE:  581-7344     FAX:  585-3898
AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT OF STUDENT ACCOUNT CREDIT
I hereby authorize the University of Utah's Income Accounting & Student Loan Services Department and the financial institution shown to initiate deposits to my account and, if necessary, debit entries and adjustments to the financial institution and account listed below, for student account refunds.  I understand that it is my responsibility to check my account to ensure that money was correctly deposited.  The University will not be liable for bank charges resulting from problems associated with direct deposit.
This authorization is to remain in full force and effect until the University has received written notification from me (or either one of us) of its termination in such time and in such manner to afford the University and the University's depository bank a reasonable opportunity to act on it.
CHECK APPROPRIATE BOX:
NEW SET-UP*	CHANGE INFORMATION*	CANCEL DIRECT DEPOSIT
STUDENT INFORMATION AND AUTHORIZATION NAME (please print) DATE     STUDENT ID# SIGNATURE (required)     PHONE NUMBER
FINANCIAL INSTITUTION BANK OR CREDIT UNION NAME ACCOUNT TYPE (check one)    Checking         Savings TRANSIT (ABA) NUMBER ACCOUNT NUMBER     START DATE
PLEASE ATTACH A VOIDED CHECK OR DEPOSIT SLIP
*Allow ten working days for required processing.
PRINT THIS FORM, COMPLETE, AND DELIVER TO THE ADDRESS LISTED ABOVE