Authorization for Direct Deposit

Authorization for Direct Deposit
I authorize Florida Multicultural District AG to deposit my pay automatically to the account(s) indicated below and, if necessary, to adjust or reverse a deposit for any pay entry made to my account in error.

This authorization will remain in effect until I cancel it in writing and within two weeks’ notice give a reasonable opportunity to act on it.

Please complete all the information below.
Requester Information
Requester Name*

First NameLast Name
Requester Address*

Street Address

Street Address Line 2

CityState

Zip Code
Bank Information
Name of Bank*
9-Digit Bank Routing Number*
Bank Account Number*
Type of Account*

CheckingSavings
Employee/Contractor Signature*

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