Direct Deposit Authorization Form

Is this authorization a...*

New AuthorizationChange to Previous AuthorizationTermination

Employee's Name:*

Employee's Address:*

Street Address

Street Address Line 2

CityState

Zip Code

Name of Bank:*

Account Number:*

9 Digit Routing Number:*

Type of Account:*

CheckingSavingsOther

PLEASE READ: A mid-month direct deposit represents pay that you have already earned; however, taxes and other payroll deductions are not withheld on the mid-month check. By choosing this option and signing below, you agree that the full amount of the mid-month deposit will be included in your month-end gross income to calculate taxes and other deductions, and then subtracted from your net pay at the end of each month.

White Plains Children's Center (WPCC) processes payroll one time per month at the end of each month. The mid-month deposit option is provided for your convenience and are not required. You may start, stop, or change the amount at any time with two-weeks written notice. Your mid-month deposit may not exceed ½ of your monthly take-home pay. Please note, that mid-month deposits will not be issued during the first or the last month of employment. If you leave WPCC any earnings due will be included in the regular month-end deposit.

Mid-Month Option*

Single Monthly Paycheck (on the last day of each month)Mid-Month Deposit (15th of each month, plus remaining pay month-end deposit)

Mid-Month Deposit Amount:*

Mid-Month Deposit Amount:

(cannot exceed ½ of your average monthly take home)

White Plains Children's Center is hereby authorized to initiate a direct deposit of my pay to the account listed above and if necessary, to initiate any debit entries to correct an erroneous credit entry to my account. This authorization will remain in effect until I modify or cancel it. I acknowledge that the origination of these transactions must comply with the provisions of U.S. law.

Signature*

Date*

Date

WPCC Direct Deposit Authorization Form