DIRECT DEPOSIT AUTHORIZATION
Please complete ALL the information below.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Bank
Account Number
9- Digit Routing Number
Amount (Choose if in a specific Dollar amount, Percentage or Entire Paycheck)
Specific Dollar amount
Percentage
Entire Paycheck
Amount in $
Amount in Percentage
Type of Account (Check One)
Checking
Savings
Attach a voided check for each bank account to which funds should be deposited (if necessary)
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I hereby authorized to directly deposit my pay to the account listed above. This authorization will remain in effect until I modify or cancel it in writing.
Employee’s Signature
Date
-
Month
-
Day
Year
Date
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