BANK DIRECT DEPOSIT FORM

Employee Name:*
Social Security Number:*
Address*

Street Address

Street Address Line 2

CityState

Zip
Name of First Bank:*
First Bank Phone Number
First Bank City, State, Zip:
First Bank Routing Number:*
First Bank Account Number:*
Type of Account*

CheckingSavings
PLEASE CHOOSE ONE OF THE FOLLOWING OF THIS ACCOUNT: (If no selection is made, all of pay will go into the account provided by default.)
Percentage of Pay (Type a Percentage) Fixed amount (Type amount) Remainder of Check (Type "Remainder")

If you are only using one bank, skip to the Authorization at the bottom of this form.
Name of Second Bank: (OPTIONAL)
Second Bank Phone Number:
Second Bank City, State, Zip:
Second Bank Routing Number:
Second Bank Account Number:
Type of Account

CheckingSavings
PLEASE CHOOSE ONE OF THE FOLLOWING OF THIS ACCOUNT:
Percentage of Pay (Type a Percentage) Fixed amount (Type amount) Remainder of Check (Type "Remainder")
Authorization

This authority will remain in full force and effect until written notification from me of its termination or change. If an error of under deposit or over deposit is distributed into my account, I authorize Citizens Bank and Trust to make correcting adjustment.
Name*

First NameLast Name
TODAY'S DATE

MonthDayYear
Date
Email to send your pay stubs as they will NOT be mailed.
example@example.com
In order to activate a direct deposit, PLEASE provide a voided check or a confirmation card from your bank that has the routing and account number listed for verification.
Please upload a copy of Voided Check or other bank document to verify account information submitted above.*

Browse Files

Cancelof
Signature*

Clear
If you have a previous bank account on file for direct deposit and would like to cancel the previous deposit information, please, sign and date here to cancel the previous deposit information.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Authorization