Direct Deposit Personal Exemption Request Form

Direct Deposit Personal Exemption Request Form

Policy:

It is the policy of the Board of Regents of the University System of Georgia that all employees be required to use direct deposit to receive payroll related payments. The policy can be found on Board of Regents website at the following location: http://www.usg.edu/policymanual/ Section 7.5.1.1 Electronic Transfer of Funds.

Your Information

First Name*

Middle Initial

Last Name*

Reason for exemption*

I currently do not have an account at an eligible financial institution and am unable to obtain an account. Attached is a letter from an eligible financial institution to this effect.

I request that the institution’s Chief Business Officer consider an exemption for my specific extreme hardship. Attached is a letter explaining my hardship.

Empl ID*

Find your Empl ID by logging into OneUSG Connect. On the Personal Details tile, this number will be below your name/position in the top left corner.

Job Title*

Department*

Email*

Work Phone*

Phone

Attachments

Please upload the applicable attachment(s) here.*

Drag and drop files here or

Certification

Typing your name and selecting the checkbox below constitutes your electronic signature, which will carry the same force and effect as an original signature.

Type Name*

I certify that the information on this form is correct and accurate to the best of my knowledge.*

Send me a copy of my responses

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