Direct Deposit Form

Direct Deposit Form
AUTHORIZATION AGREEMENT FOR AUTOMATED DEPOSITS (ACH CREDITS)

I hereby authorize the City of Guymon to make direct deposit of my paycheck into the checking and/or saving account indicated below.
Primary
Name of Bank:*
Routing Number:*
Checking Account #:*
Savings Account #:*
Amount to be deposited:*
$ or %, please specify which one you choose.

Secondary
Name of Bank:
Routing No.:
Checking Account #:
Savings Account #:
Amount to be deposited:
$ or %, please specify which one you choose.

Third
Name of Bank:
Routing No.:
Checking Account #:
Savings Account #:
Amount to be deposited:
$ or %, please specify which one you choose.

Fourth
Name of Bank:
Routing No.:
Checking Account #:
Savings Account #:
Amount to be deposited:
$ or %, please specify which one you choose.

Name on Account:*

First NameLast Name
Employee Signature

Clear
Should be Empty: