TELICS Direct Deposit Form

Direct Deposit Enrollment Request Form for Payroll Authorization agreement for automatic deposits (ACH Credits) I authorize TELICS (Issuer) and Bank of America (the financial institution) to electronically deposit my net pay to the specified account each payday.

Select one of the following:

CheckingSavings

Bank Name

Do you want to put a certain Amount in this account or a percentage?

What Percentage?

What Amount?

Bank Routing Number

Bank Account Number

Would you like to split your deposits to another bank account?

YesNo

Select one of the following:

CheckingSavings

(2)Do you want to put a certain Amount in this account or a Percentage?

(2)What Percentage?

(2)What Amount?

2nd Bank Name

2nd Bank Routing Number

2nd Bank Account Number

If monies to which I am not entitled are deposited to my account, I authorize TELICS (issuer) to direct the financial institution to return said funds. This authority will remain in effect until I have filed a new authorization, or until this authorization is revoked by me in writing, or upon termination of my employment with TELICS.

Name

FIRST NAMEMIDDLE INITIALLAST NAME

Address

ADDRESS

Street Address Line 2

CITYSTATE

ZIP CODE

PHONE NUMBER

Email Address

Social Security Number

SIGNATURE

DATE

Date

Upload a picture of a voided check or deposit slip . If you are using a deposit slip, be sure the routing numbers match what shows on your checks.