Fletcher ACH Form

Direct Deposit

Payment Delivery Authorization
Banner ID (Office Use Only)
Date of Entry or Update

MonthDayYear
Date
Entered By Initials*
Name or Business Name*
As it appears on W-4/W-9)
Remittance Email Address*
example@example.com
Contact Name*
Contact Phone Number*
Format: (000) 000-0000.
Contact Email*
example@example.com
I authorize Fletcher Technical Community College (FTCC) to initiate electronic credit entries to the account I have indicated below for all non-payroll related payments due to me.

**Please note, you will receive a confirmation email when any change to your information is made. Since we are a part of the Louisiana Community and Technical College System this email will come from LCTCS@LCTCS.edu.**

For any funds paid to me which are not due and owing to me, through direct deposit, I hereby agree and authorize FTCC to initiate compensating electronic transactions to reverse any over or incorrect payments. In the event such electronic transactions are unsuccessful, FTCC will notify me of the amount to be returned.

I acknowledge that the origination of ACH transactions to my account must comply with the provisions of Louisiana and U.S. law.
Financial Institution Name*
Bank Account Number*
Financial Institution Routing ABA Number*
Account Name*
CheckingSavings
How to Revoke or change your Authorization:

This authority will remain in effect until I change or cancel it in writing with FTCC via email at finance@fletcher.edu or via postal mail to 1407 Hwy 311, Schriever, LA 70395.
Discontinue my direct deposit (Please update your mailing address below)
Address Line 1
Address Line 2

Street Address Line 2

City, State, Postal CodeState / Province

Postal / Zip Code
Signature of Bank Account Authorized Signer

Clear
Date

MonthDayYear
Date
W9 Information

Please upload your W9 or find links below for a copy of the W9 Form
W9 Upload

Cancelof
W-9 Form

If you need a copy of the W-9 Form please visit: https://www.irs.gov/pub/irs-pdf/fw9.pdf or https://www.irs.gov/forms-instructions.
Should be Empty:

Direct Deposit

W9 Information