DIRECT DEPOSIT SIGN-UP FORM by malj

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									                  DIRECT DEPOSIT SIGN-UP FORM
YOU MAY CHOOSE UP TO THREE ACCOUNTS. IF YOU CHOOSE THREE ACCOUNTS, THE LAST
ACCOUNT MUST BE FOR THE REMAINING AMOUNT OWED TO YOU. PLEASE ATTACH A COPY OF
A CHECK FOR A CHECKING ACCOUNT OR A COPY OF A DEPOSIT SLIP FOR A SAVINGS
ACCOUNT. PLEASE CALL YOUR BANK TO VERIFY ALL INFORMATION. IT TAKES AT LEAST ONE
FULL PAYPERIOD FOR A DIRECT DEPOSIT CHANGE TO OCCUR. PLEASE CHECK YOUR PAYSTUB
FOR A LIVE CHECK UNTIL YOU ARE SURE THE DIRECT DEPOSIT CHANGE HAS TAKEN
EFFECT.

1. ______________________________                        ________________________________________
             BANK NAME                                              ACCOUNT NUMBER
          Checking Account                                           I WISH TO DEPOSIT $                   or
          Savings Account                                            ENTIRE NET AMOUNT
TRANSIT (ROUTING) NUMBER #

2.
                  BANK NAME                                              ACCOUNT NUMBER
          Checking Account                                           I WISH TO DEPOSIT $                   or
          Savings Account                                            ENTIRE NET AMOUNT
     TRANSIT (ROUTING) NUMBER

3.
                  BANK NAME                                              ACCOUNT NUMBER
           Checking Account                                          I WISH TO DEPOSIT $                  or
           Savings Account                                           ENTIRE NET AMOUNT
     TRANSIT (ROUTING) NUMBER                             #
I hereby authorize my employer (hereinafter "Company") to deposit any amounts owed me by initiating credit
entries to my account(s) at the financial institution(s) (hereinafter "Bank") indicated on this form. Further, I
authorize Bank to accept and to credit any credit entries indicated by Company to my accounts. In the event that
Company deposits funds erroneously into my account, I authorize Company to debit my account for an amount not
to exceed the original amount of the erroneous credit. This authorization is to remain in full force and effect until
Company and Bank have received written notice from me of its termination in such time and in such manner as to
afford Company and Bank reasonable opportunity to act on it. The Company is not responsible for overdraft
charges due to non-sufficient funds. Employee takes full responsibility in making sure funds are available
each payday.

DATE:                                       OFFICE LOCATION
EMPLOYEE NAME (Print):
EMPLOYEE SIGNATURE:
SOCIAL SECURITY NUMBER:




                                                    Form 4121
                                                     03/18/10

								
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