EMPLOYEE DIRECT DEPOSIT AUTHORIZATION
Employee Name: Social Security #:
I hereby authorize [COMPANY NAME] to initiate credit entries or such adjusting entries, either credit or debit which are necessary for corrections, to my account(s) indicated below and the depository(ies) named below to credit (or debit) the same such account.
Depository Account #1: Bank Name: Bank Street Address: City: Bank Phone Number: Depository Account #2 Bank Name: Bank Street Address: City: Bank Phone Number: Depository Account #3 Bank Name: Bank Street Address: City: Bank Phone Number: State: Type of Account: Zip Code: Checking Savings State: Type of Account: Zip Code: Checking Savings State: Type of Account: Zip Code: Checking Savings
This authority is to remain in full force and effect until [COMPANY NAME] has received written notification from me of its termination in such time and in such manner as to afford [COMPANY NAME] a reasonable opportunity to act on it. I understand there will be approximately two (2) weeks of pre-noting (live checks) until my direct deposit is initiated. Employee Signature: Date:
Please attach a voided check for each checking account and/or a deposit slip for each savings account.
[COMPANY NAME] USE ONLY
Date Received: Date Processed: Received by: Processed by: