Authorization for Direct Deposit

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You are required to participate in Direct Deposit as an employee of Santaquin City

Are you a returning employee?*

YesNo

If Yes, as a RETURNING EMPLOYEE I authorize Santaquin City Corp. to reinstate automatic deposits to the SAME ACCOUNT(S) as was done during my most recent employment.

YesNo - Please fill out the Personal Banking Information below

AUTHORIZATION FOR DIRECT DEPOSIT STATEMENT: I hereby authorize Santaquin City Corp. to initiate automatic deposits to my account at the financial institution named below, (or) if I am a returning employee, I authorize Santaquin City to reinstate my automatic deposits. I also authorize Santaquin City Corp. to make withdrawals from this account in the event a credit entry is made in error.

I agree not to hold Santaquin City Corp. responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in depositing funds to my account.

This agreement will remain in effect until Santaquin City Corp. receives a written notice of cancellation from me or my financial institution, or until I submit a new/updated direct deposit form to Human Resources.

I agree to the above Authorization for Direct Deposit Statement*

Yes, I agree

Account Information

Personal Banking Information

	Name of Financial Institution	Routing Number	Account Number	Dollar Amount to be Deposited (Type ALL to have your entire check deposited)	Account Type (Checking/Savings)
Account 1
Account 2
Account 3
Account 4

Under penalties of perjury, I declare that I have examined this Authorization for Direct Deposit Form, and to the best of my knowledge and belief, it is true, correct, and complete. I understand this authorization is not valid unless I sign and date below:

Employee Electronic Signature Verifying Account Information and Authorization*

Employee Name: *

First NameLast Name

Today's Date:*

Date

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