Direct Deposit Form
Required: Please upload a voided check or bank-issued Direct Deposit Authorization Form so we can verify the account information you are submitting before processing your request.
Upload a Voided Check or Bank Direct Deposit Authorization Form for Each Account
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Email
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example@example.com
Name
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First Name
Last Name
SSN
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Ful Social Security # required for employee verification
Bank Account
Submit 1 form per bank account.
Name of Financial Institution
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City
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Routing #
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Account #
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Name on Account
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Account Type
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Checkings or Savings
Deposit
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$ or %
Authorization
I hereby authorize Employer, either directly or through its payroll service provider, to deposit anyamounts owed me, by initiating credit entries to my account at the financial institution (hereinafter"Bank" indicated on this form. Further, I authorize Bank to accept and to credit any credit entriesindicated by Employer, either directly or through its payroll service provider, to my account. In theevent that Employer deposits funds erroneously into my account, I authorize Employer, either directlyor through its payroll service provider, to debit my account for an amount not to exceed the originalamount of the erroneous credit. This authorization is to remain in full force and effect until Employer and Bank have received writtennotice from me of its termination in such time and in such manner as to afford Employer and Bankreasonable opportunity to act on it.
Signature
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Date
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/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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