Direct Deposit Enrollment
Use this form to enroll in or update your direct deposit information for payroll. Your submission is encrypted and securely stored to protect your financial privacy. If you need to make changes in the future, simply revisit this form and resubmit your updated information.For any questions or concerns regarding payroll or banking details, please contact Office Management directly.
Name
*
First Name
Last Name
Bank Name:
*
Bank Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Account Type
*
Checking
Savings
HSA Account
Other
Account #
*
Routing Numbers
*
Percentage of paycheck to deposit into the primary account?
*
Default is 100%
Please upload voided check or payroll information on bank letterhead for the primary account.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Would you like to assign a secondary account for direct deposit?
*
Please Select
Yes
No
Bank Name:
*
Bank Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Account Type:
*
Checking
Savings
HSA
Other
Account#
*
Routing #
*
Percentage of pay check to deposit to the secondary account?
*
All Accounts Must = 100%
Please upload voided check or payroll information on bank letterhead for the secondary account.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Would you like to assign a tertiary account for direct deposit?
*
Please Select
Yes
No
Bank Name:
*
Bank Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Account Type:
*
Checking
Savings
HSA
Other
Account#
*
Routing #
*
Percentage of pay check to deposit to the tertiary account?
*
All Accounts Must = 100%
Please upload voided check or payroll information on bank letterhead for the tertiary account.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
*
“I certify that the information provided is true and accurate and I take full responsibility for the integrity of the information provided. .”
Signature
*
Continue
Continue
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