PAYROLL DIRECT DEPOSIT FORM

PAYROLL DIRECT DEPOSIT FORM
Store Location:*
Hire Date

MonthDayYear
Date
Effective Date

MonthDayYear
Date
To enroll in Direct Deposit, simply fill out this form and give it to your supervisor. On a separate sheet, attach a voided check for each checking account, or a deposit slip for savings.

Important! Please read and sign before completing and submitting.

I hereby authorize my employer (hereinafter “Company”) to deposit any amounts owed me by initiating credit entries to my accounts at the financial institution/s indicated on this form. Further, I authorize the financial institution/s to accept and to credit any credit entries indicated by Company to my accounts. In the event that Company deposits funds erroneously into my account, I authorize Company 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 Company and financial institution/s have received written notice from me of its termination in such time and in such manner as to afford Company and financial institution reasonable opportunity to act on it.
Employee Name
ID
Employee Signature*

Clear
Today's Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Choose Account*

New AccountChange to Existing Account
Account Information
Make sure to indicate what kind of account, along with the amount to be deposited if less than your total net paycheck.
1. Bank Name/City/State
Routing/Transit#*
Enter the 9-Digit Routing Number - Including the beginning zero(If present) - Example: 012345678
Routing/Transit#

CheckingSavings
Account Number:*
Enter the Bank Account Number (minimum 6 and max 17 digits) Example: 012345678
I wish to deposit........
or

Entire Net Amount
2. Bank Name/City/State
Routing/Transit#
Enter the 9-Digit Routing Number - Including the beginning zero(If present) - Example: 012345678
Routing/Transit#

CheckingSavings
Account Number
Enter the Bank Account Number (minimum 6 and max 17 digits) Example: 012345678
I wish to deposit........
or

Entire Net Amount
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REV:05/05/2025
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PAYROLL DIRECT DEPOSIT FORM

Account Information

REV:05/05/2025