Direct Deposit Authorization

DIRECT DEPOSIT AUTHORIZATION
Fill in the boxes and Sign the form
Name*

First NameMiddle InitialLast Name
Social Security Number
Work Phone
Action

NewChangeCancel
Effective Date
Month
Date
Year
Name of Financial Institution
Account Number (Includes hyphen but not spaces and special symbols)
Type of Account

CheckingSavings
Routing Transit Number [Must be 9 characters)(The first two numbers was 01 through 12 or 21 to 32)
Type of Ownership

SoloJointOther
By signing this agreement I authorize the account indicated above for the purpose of expense and/ or payroll. I also authorize to initiate if necessary, debit entries and adjustments for any credit entries made in error.
Signature*

Clear
Date*

MonthDayYear
Date
If the account is a joint account or in someone else's name, that individual must also agree to the term stated above before signing below.
Signature*

Clear
Date*

MonthDayYear
Date
HOW TO COMPLETE THIS FORM

1. Fill all the necessary data on boxes above

2. Sign and Date Form

TIP: Call your financial institution to make sure that they will accept direct debit.

TIP: Verify your account number and routing transit number with your financial

institution.

TIP: Do not use deposit slip to verify the routing number.
Should be Empty:

DIRECT DEPOSIT AUTHORIZATION