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PAYROLL DIRECT DEPOSIT AUTHORIZATION

VIEWS: 23 PAGES: 2

									                         PAYROLL DIRECT DEPOSIT AUTHORIZATION
                                                   C. J. FOODS INC.

Purpose of Authorization: (Check one)
_____New Authorization           ____Changes to existing authorization    ____ Cancellation
(Complete A,B,C and F)               (Completed (A,B,D and F)            (Complete A and E)



A.      Employee Information

_____________________________________                     ________________________________
Employee’s Name (please print)                            Social Security Number

_____________________________________
Department or Organization



B.      Banking/Financial Institution Information

______________________________________                    ________________________________
Name of Bank/Financial Institution                        Phone # of Bank
______________________________________                    ________________________________
______________________________________                    Routing/ABA No.
Address                                                   _______________________________            Checking
                                                          Account #
                                                                                                     Savings


C.      New Authorization Statement
I authorize and request my employer to send the new amount due from payroll, retirement, or living allowance to the financial
institution indicated above for direct deposit to my account. I understand I may terminate this agreement at any time by
completing another Payroll Direct Deposit Authorization form and sending it to Payroll Services, allowing a reasonable time
for my employer to act upon my request for termination. I hereby authorize C. J. FOODS, INC. to initiate credit entries and
initiate, if necessary, debit entries and adjustments for any credit entries in error to my account as indicated above and
depository named above to credit and/or debit the same to such account. I understand that C.J. FOODS, INC. has the right to
terminate this service at any time at their discretion.

___________________________________                       _______________________________
Employee’s signature                                      Date signed



D.      Change Authorization Statement
I authorize and request my employer to make the changes indicated on this form for automatic deposit of payroll, retirement,
or living allowance to my account.

____________________________________                      _________________________________
Employee’s signature                                      Date signed



E.      Cancellation Statement
I request that my employer terminate my authorized direct deposit of net amount due from payroll, retirement, or living
allowance to my account. I will allow a reasonable time for my employer to act upon my request to terminate this agreement.

_____________________________________                     __________________________________
Employee’s signature                                      Date signed



F.      Attach a voided check and return form to payroll office.
Net Pay Deposited to Primary Account on Front:

Deductions to Net Pay:


Deduction Amount         Checking/Savings            ABA #                Account #

__________________       __________________   _________________________   ______________

__________________       __________________   _________________________   ______________

__________________       __________________   _________________________   ______________

__________________       __________________   _________________________   ______________

__________________       __________________   _________________________   ______________

__________________       __________________   _________________________   ______________

__________________       __________________   _________________________   ______________

__________________       __________________   _________________________   ______________

__________________       __________________   _________________________   ______________

								
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