Employee ACH Payment Enrollment Form (Direct Deposit)

    Payee name

    Vendor Number/Employee (SSI AP USE ONLY)

    Your Email

    Telephone Number

    Street Address

    City

    Select State

    Zip Code

    Please Select ONE
    Initial Set UpChange of Account InfoDiscontinue ACH

    Financial Institution Information

    Bank Name

    Bank Address

    Bank Account Number

    Bank Routing Number

    Authorization: I authorize Student Services, Inc. of West Chester University and the financial institution listed above to deposit payments automatically into the checking account noted above each time a payment is made and, if necessary, to adjust or reverse a deposit for any entry made to this account in error. This authorization will remain in effect until I have cancelled it in writing and in such time as to afford Student Services, Inc. of West Chester University a reasonable opportunity to act upon it. I will notify Student Services, Inc. of West Chester University of any changes made to my checking account.

    Signature (Please Print)

    Date

    Signature

    Please attach a copy of a VOID check (Required): Accepted file types are .doc, .jpeg and .pdf