HTML Preview Blank Payroll Check page number 1.
Payroll Check Direct Deposit Authorization
(for LANS non-craft salary & wage payments only)
Note: Direct Deposit authorizations are available through Oracle LANL Worker Self Service with A-Level access.
Limit 5 Direct Deposit authorization accounts per employee
Financial Institution Name:
Routing/Transit Number:
(requires nine digits)
Account Number:
Type of Account (check one): Checking Savings
A separate form is required for each account transaction.
Type of Transacton Deposit Type (check one):
New account request _________% of Net Pay
(New account authorizations require a voided check,
document or letter from the institution indicating
Dollar Amount $ __________
routing/transit number & account number.
Remainder of Net Pay
* Any first time Direct Deposit requests (canceling and setting up a new 100% account, or if you are a new hire), go through a pre-note process
through the banking system before the first Deposit is made. You should expect to receive a paper check mailed to your mail stop.
The payroll after the pre-note process, with no issues, will then be direct deposited into your bank.
Change in amount __________% of Net Pay
Dollar Amount $ ___________
Remainder of Net Pay
Cancel __________% of Net Pay
Dollar Amount $ ___________
Remainder of Net Pay
I hereby authorize Los Alamos National Laboratory, hereinafter called the Laboratory, to initiate credit entries and, if
necessary, debit entries and adjustments for any credit entries in error to my account listed on this form.
Printed Name: Z Number / Lab phone number
Signature: Date:
This form is to remain in effect until The Laboratory has received written notification from me of its termination in such time to
afford The Laboratory and the Financial Institution a reasonable opportunity to act on it. (Rev. 4/2015)
Return completed form to:
Payroll - MS P238 - Otowi Bldg. Basement, 1st Floor
Or FAX to 505.665.5562
(Original need not be sent - FAX is sufficient)
Or E-mail to Payro[email protected]
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