Direct Deposit Form

WAGE PAYMENT ELECTION AND CONSENT FORM
EMPLOYEE INFORMATION

(print and complete all fields)
Name*

First NameMiddle InitialLast Name
Date of Birth (mm/dd/yyyy)*

MonthDayYear
Date
Social Security Number*
(PO Box is not allowed if electing ALINE Card as wage payment method)
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Is your Mobile Phone the same as your Home Phone?*

Same as homeDifferent from home
Mobile Phone*
Email Address*
example@example.com

Consent to Deposit Wages
I authorize my employer (or its payroll service provider) to initiate credit entries each pay date to deposit my pay (either net or a portion thereof) into the checking, savings or ALINE Card account selected in this election and consent (the “Account”). If funds to which I am not entitled are deposited to my Account, I authorize my employer (or its payroll service provider), to initiate any action to reverse or correct an erroneous credit entry to my Account and to direct the bank to return said funds to my employer (either directly or through its payroll service provider), to the extent permitted by applicable law. I will review my pay statement to ensure that my wages are being deposited correctly into my Account each payroll period. I understand that I can change my election at any time by contacting my employer and that this authorization replaces any previous authorizations and will remain in full force and effect until my employer (or its payroll service provider) has received written notification from me of its termination and my employer (or its payroll service provider) and the bank has had a reasonable opportunity to act on said termination.
Consent to Electronic Pay Statements
I agree to receive and access all of my pay statements on or before each regular pay day electronically on the myALINE Website, a secure website, rather than receiving a paper statement, until I withdraw my consent. I understand that I may retain a copy of the pay statement by saving it to my computer or by printing a hard copy of it. I understand that I should not save my statement to a public computer as others may see my statement. (Note: Your statements will remain on the secure website for 3 years. If you want to retain a copy for a longer period, you must either print a copy or save an electronic copy.)

I understand that I may withdraw this authorization at any time. I acknowledge that the mere request for a paper pay statement will not be considered withdrawal of my consent. I understand this consent applies to pay statements furnished every pay period until my consent is withdrawn. (Note: The withdrawal of your consent will not be effective and you will not start receiving paper statements for 1 or 2 additional payroll cycles.)
Employee Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

WAGE PAYMENT ELECTION AND CONSENT FORM

EMPLOYEE INFORMATION

Wage Payment Election

Direct Deposit

ALINE Card

Consent to Deposit Wages

Consent to Electronic Pay Statements