Direct Deposit Authorization Form (2026)

Direct Deposit Authorization for Employee or Contractor

A copy of a void check or bank form showing employee name, bank name, routing number and account number must be uploaded.
Employer Name
Payee Name

First NameLast Name
Last 4 digits of SSN
Payee Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Direct Deposit (Primary Account)

If splitting, enter paycheck allocation (50%, $25, etc.)

Bank Name

Routing NumberAccount Number

Checking or Savings
Bank Documentation

Browse Files

Cancelof
Direct Deposit (Secondary Account)

If splitting, enter paycheck allocation (50%, $25, etc.)

Bank Name

Routing NumberAccount Number

Checking or Savings
Bank Documentation

Browse Files

Cancelof
Direct Deposit (Tertiary Account)

If splitting, enter paycheck allocation (50%, $25, etc.)

Bank Name

Routing NumberAccount Number

Checking or Savings
Bank Documentation

Browse Files

Cancelof
Notes
Insert information not found elsewhere on this form.
Direct Deposit Authorization

I hereby authorize Clergytech, Inc and its payroll processor to initiate Automated Clearing House (ACH) credit entries to the financial institution account indicated below for the purpose of depositing my wages, salary, and/or other compensation. I further authorize the initiation of debit entries and adjustments to correct any erroneous credit entries made to my account.

This authorization shall remain in effect until I provide written notice of revocation to Clergytech, Inc. at least three (3) business days prior to the next scheduled pay date, allowing a reasonable opportunity to act on the revocation. I understand that it may take up to two (2) payroll cycles for this authorization to take effect or for changes to be processed.

I certify that I am the owner or an authorized user of the bank account provided and that the account information is accurate. I agree to notify [Company Name] promptly of any changes to my account information.

Records of this authorization will be retained in accordance with applicable Nacha Operating Rules.
Submitted By

First NameLast Name
Submitter's Email Address
example@example.com
Signature
Should be Empty:

Direct Deposit Authorization for Employee or Contractor