Direct Deposit Form

Note: Jotform uses Secure Sockets Layer (SSL) technology for both server authentication and data encryption, helping to ensure that your data is safe and secure.

AUTHORIZATION FOR DIRECT DEPOSIT STATEMENT: I hereby authorize Wingmom to initiate automatic deposits to my account at the financial institution named below. I also authorize Wingmom to make withdrawals from this account in the event a credit entry is made in error.

I agree not to hold Wingmom responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in depositing funds to my account.

This agreement will remain in effect until Wingmom receives a written notice of cancellation from me or my financial institution, or until I submit a new/updated direct deposit form.

I agree to the above Authorization for Direct Deposit Statement*

Yes, I agree

Please indicate the action needed*

This is an initial set-upThis is an account update

Account Information

Personal Banking Information*

Rows	Name of Financial Institution	Routing Number	Account Number	Re-enter Account Number	Account Type (Checking/Savings)
Account

Tip Acceptance

For the purpose of electronic tips, please provide your unique identifier for the platforms that you are able/willing to accept payment on. PAY REIMBURSEMENT CANNOT BE PAID THROUGH THESE PLATFORMS.

Place an "n/a" for no answer*

Name *as it appears on the Bank Account: *

First NameLast Name

Today's Date:*

Date

Email*

example@example.com

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Under penalties of perjury, I declare that I have examined this Authorization for Direct Deposit Form, and to the best of my knowledge and belief, it is true, correct, and complete. I understand this authorization is not valid unless I sign and date below:

Staff Electronic Signature Verifying Account Information and Authorization*