Direct Deposit Form

Payroll Manager-Please complete this section and enter data into your ADP Payroll system for employee enrollment. Then contact your CSR or AE for further instructions on how to update your employee's direct deposit information to ADP. NOTE: YOUR COMPANY NAME MUST BE FILLED IN BEFORE DISTRIBUTING THIS FORM TO YOUR

EMPLOYEE FOR COMPLETION. (Please print

Company Code

(referred to herein as "Employer")

Employee File Number

Payroll Mgr. Name

Payroll Mgr. Signature

Important! Please read and sign before completing and submitting.

I hereby authorize Employer, either directly or through its payroll service provider, to deposit any amounts owed me, by initiating credit entries to my account at the financial institution (hereinafter "Bank") indicated on this form. Further, I authorize Bank to accept and to credit any credit entries indicated by Employer, either directly or through its payroll service provider, to my account. In the event that Employer deposits funds erroneously into my account, I authorize Employer, either directly or through its payroll service provider, to debit my account for an amount not to exceed the original amount of the erroneous credit.

This authorization is to remain in full force and effect until Employer and Bank have received written notice from me of its termination in such time and in such manner as to afford Employer and Bank reasonable opportunity to act on it.

Employee Name*

Social Security #*

Employee Signature*

Date*

Date

Account Information

The last item must be for the remaining amount owed to you. To distribute to more accounts, please complete another form.

Make sure to indicate what kind of account, along with amount to be deposited, if less than your total net paycheck.

Bank Name/City/State*

Routing/Transit #*

Account Number*

CheckingSavingsOther

I wish to deposit $amount or Entire Net Amount

Employers must keep each original employee enrollment form on file as long as the employee is using FSDD, and for two years thereafter.

Employee Direct Deposit Enrollment Form