Direct Deposit Form (PAYLOCITY)

DIRECT DEPOSIT FORM (PAYLOCITY)
Name*
Last 4 digits of SSN*
Phone*
LEVERAGE HEALTH, INC
I hereby authorize PAYLOCITY to initiate credit entries to my (check one):*

CheckingsSavings
If you would like to add a Deposit Account, please select one:*

NET PAY
Account Number*
Financial Institution*
Name of the bank
Branch
State
Zip Code
Financial Institution Routing Number*
Must attach voided check (direct deposit only processed with a copy of voided check on file). Please verify the direct deposit information has been updated in the Employee Portal prior to submitting your next claim to Paylocity.
UPLOAD VOIDED CHECK OR SCREEN SHOT OF ACCOUNT INFORMATION*

Cancelof
I here authorize LEVERAGE HEALTH, INC DBA/MIND & MOBILITY hereby referred to as "Company" to initiate credit entries for sums to and payable to me to my checking, savings or other account indicated below and the Financial Institution named below, hereafter referred to as "Depository" to credit the same to such account. I also authorize Company to initiate debits for sums due to the Company for erroneous deposit or deposits at the Depository.
Employee Name*
Date*

MonthDayYear
Date
Employee Signature*

Clear
User_ID
Should be Empty:

DIRECT DEPOSIT FORM (PAYLOCITY)