Direct Deposit Enrollment / Change Form

Direct Deposit Enrollment / Change Form
Company Name and/or Client Number
(Print Legible First and Last Name)
First NameLast Name
Employer/Employee: Retain a copy of this form your records
COMPLETE TO ENROLL / ADD / CHANGE BANK ACCOUNTS*

Add new accountUpdate existing account
Replace existing (Account # being replaced)*
Type of Account:*

CheckingSavings
Account Holder's Name*

First NameLast Name
If a Trustee or Custodial for a Minor, please list complete title of account. (Example: John Doe Custodian for Minor Jane Doe)
Routing/Transit Number*
Account Number*
Financial Institution ("Bank") Name*
("Bank") Name if other*
Deposit of Pay (select one):
% of net
Specific dollar amount $ .00*
Remainder of Net*
CONFIRMATION STATEMENT
I authorize my employer/company to deposit my earnings into the bank account(s) specified above, and, if necessary, to electronically debit my account to correct erroneous entries. I certify my account(s) allow these transactions. Furthermore, I certify that the above listed account number accurately reflects my intended receiving account. I agree that direct deposit transactions I authorize comply with all applicable laws. My signature below indicates that I am agreeing that I am either the accountholder or have the authority of the accountholder to authorize my employer/company make direct deposits into the named account. I understand that this authorization will remain in full force and effect until I notify Company in writing that I wish to revoke my authorization. I understand that the Company requires at least 5 business days prior notice to cancel this authorization.
Signature*

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Date*

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Date
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Direct Deposit Enrollment / Change Form

(Print Legible First and Last Name)

CONFIRMATION STATEMENT