Direct Deposit Authorization Form

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									Direct Deposit Authorization
Form
This Direct Deposit Authorization Form can be used by companies that want to offer
direct deposit of paychecks to employees. Direct deposit is convenient method for
employees to receive paychecks and helps ensure that they are paid on time. This form
obtains the necessary information to authorize, update or cancel direct deposit
payments into an employee’s bank account. This form should be used by a company’s
payroll department to offer direct deposit of paychecks.
                                    DIRECT DEPOSIT AUTHORIZATION FORM
___________________________ _____________________________ __________ ____________________
Last Name                     First Name                  Middle Initial Social Security No.
(Please Print Legibly)

ACCOUNT DESIGNATION:
Check only ONE. Deposit may only be made to ONE account. No combination of accounts.

                     CHECKING (Contact your bank to verify the correct numbers)
                      IMPORTANT: Attach voided check (for checking deposit) to ensure proper processing of direct deposit
                      request.

Routing Number ___ ___ ___ ___ ___ ___ ___ ___ ___

Account Number _______________________________

                     SAVINGS (Contact your bank to verify the correct numbers)
                          IMPORTANT: Attach deposit slip (for savings deposit) to ensure proper processing of direct deposit
                      request.

Routing Number ___ ___ ___ ___ ___ ___ ___ ___ ___

Account Number _______________________________

CHANGES TO AN EXISTING ACCOUNT
Check only ONE. IMPORTANT! Attach voided check (for checking) or deposit slip (for savings) for change of account.

                     STOP my participation in the program.

                     CHANGE my current Direct Deposit Program – Change Financial Institutions and/or account number to:

Routing Number ___ ___ ___ ___ ___ ___ ___ ___ ___

Account Number _______________________________

STATEMENT OF AGREEMENT FOR ABOVE SELECTIONS: My signature below authorizes my employer and its agents, including financial institutions, to
initiate electronic credit entries, and if necessary, debit entries or adjustments for any credit entries in error to my checking and/or savings accounts listed above. I
confirm that the account listed above is in my name and I am an authorized signer. This authorization will remain in effect until I have informed my employer in
writing that I wish to cancel it – and my employer processes the cancellation.


Employee Signature: ______________________________________________                                       Date: ____________________________




                                            Attach Voided Check or Savings Account Deposit Slip




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