Direct Deposit Authorization

DIRECT DEPOSIT AUTHORIZATION
OFFICE STAFFCOMPANY DRIVERCONTRACTORNEWACCOUNT INFORMATION CHANGECANCEL
NAME:
EMPLOYEE ID#:
ADDRESS:

Street Address

Street Address Line 2

CITY:ST:

ZIP CODE:
ACCOUNT INFORMATION
Name of Bank / Financial Institution:
Address:
Checking
Savings
Flat Amount
or Net Pay
Routing No:
Account No:
BUSINESS/COMMERCIAL ACCT
PERSONAL ACCT
ACCOUNT INFORMATION
Name of Bank / Financial Institution:
Address:
Checking
Savings
Flat Amount
or Net Pay
Routing No:
Account No:
BUSINESS/COMMERCIAL ACCT
PERSONAL ACCT
I understand:
- Direct Deposit status may not be activated until 10 days following a $0 test transaction for NEW or CHANGE authorization.
- I must submit a new authorization form if I change name, institution, branch, type of account, etc. or close my account. My pay may be delayed until my financial institution returns my rejected deposit. Any fees associated with stop payment or direct deposit reversal will be charged back to the employee or contractor.
- Direct Deposit status will be temporarily suspended if wages are garnished.
This authorization replaces any previous requests made by me and is to remain in effect until changed or cancelled by submission of a new Direct Deposit Authorization Form.
Signature:

Clear
Date:

MonthDayYear
Date
Attach copy of Voided Check

Area Below of Payroll / HR Use Only
Date entered into system:

MonthDayYear
Date
Initials:
Should be Empty:

DIRECT DEPOSIT AUTHORIZATION