EMPLOYEE DIRECT DEPOSIT AUTHORIZATION FORM

EMPLOYEE DIRECT DEPOSIT AUTHORIZATION FORM
Employee Name:
Employee SSN ( First Three Digits):
Employee SSN (Middle Two Digits):
Employee SSN ( Last Four Digits)
I hereby authorize Balance Home Health Services (Employer) to initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit entries in error to my account as follows:
Banking Information
Primary Bank Name:
Bank Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Bank Routing Number:
Branch Street Address:
Branch City, State and Zip Code:
Name on Account:
Type of Account ( Checkings or Savings )
Account Number
Indicate Specific Amount ( $ ):
Or Indicate Percentage ( % ):
Secondary Bank Name:
Bank Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Bank Routing Number:
Branch Street Address:
Branch City, State and Zip Code
Name on Account:
Type of Account ( Checking or Savings ):
Account Number
Indicate Specific Amount ( $ ):
Or Indicate Percentage ( % ):
at the financial institution(s) as indicated. I further authorize the financial institution named in this authorization form to credit and/or debit such account(s).
I understand that this authorization remains in effect until the "Employer" receives from me, in writing, notification to terminate the authorization in such a time and a manner as to afford the "Employer" and my financial institution a reasonable time to act upon it. I acknowledge that I have been informed that it will take a reasonable amount of time (up to 15 business days) to complete the initial set up for my bank and account and that all paychecks prior to the full implementation will be delivered to me as fully negotiable paychecks.
Employee/Account Holder Signature
Type or Print Name - CLEARLY
Date Authorized

MonthDayYear
Date
Joint Account Holder Signature (if required)
Type or Print Name - - CLEARLY
Date Authorized

MonthDayYear
Date
Employee Direct Deposit Authorization
Should be Empty:

EMPLOYEE DIRECT DEPOSIT AUTHORIZATION FORM

Banking Information