AUTHORIZATION FOR DIRECT DEPOSIT

AUTHORIZATION FOR DIRECT DEPOSIT
REMINDERS
● Provide all information requested completely as possible for all accounts new and old.

● If you are having funds deposited into a checking account, attach a VOIDED BLANK CHECK for the account.

● This form must be signed and dated by the employee to be valid. If not, the direct deposit will not be processed.
Employee Name:
SSN:
Company:
ACCOUNT #1
Account Type:

Checking Savings
Name of Financial Institution
Routing Number
Account Number
Type a question

Entire Net Pay % of Net Pay $ of Net Pay
Net Pay %
Net Pay $ Amount
ACCOUNT #2
Account Type:

Checking Savings
Name of Financial Institution
Routing Number
Account Number
Type a question

% of Net Pay $ of Net Pay Remainder of Net Pay
Net Pay %
Net Pay $ Amount
ACCOUNT #3
Account Type:

Checking Savings
Name of Financial Institution
Routing Number
Account Number
Type a question

% of Net Pay $ of Net Pay Remainder of Net Pay
Net Pay %
Net Pay $ Amount
ACCOUNT #4
Account Type:

Checking Savings
Name of Financial Institution
Routing Number
Account Number
Type a question

% of Net Pay $ of Net Pay Remainder of Net Pay
Net Pay %
Net Pay $ Amount
I hereby authorize the Company named above, via their payroll service provider (Access1Source-NC,LLC) and the financial institution(s) named above to deposit my pay automatically to the specified accounts. Adjusting entries to correct errors are also authorized. Please continue this authorization until I cancel it in writing.
Upload Copy/Copies of Voided Check(s)

Browse Files

Cancel of
Employee Signature

Clear
Date

Month Day Year
Date
Should be Empty:

AUTHORIZATION FOR DIRECT DEPOSIT

REMINDERS

ACCOUNT #1

ACCOUNT #2

ACCOUNT #3

ACCOUNT #4