SCSEP DIRECT DEPOSIT FORM

Enrolling in direct deposit is easy! Just follow the instructions below:
- Submit either a voided check or documentation from the financial institution verifying routing and account numbers. “Checking” or “Savings” account must be designated below;
- Indicate whether you would like your total check or a partial amount of your check deposited;
- To have part of your check deposited at one financial institution and the balance at another institution, two authorization agreements must be completed;
- Please submit this form or return the completed form and backup documentation by mail to Vantage Aging, Payroll Coordinator, 388 S. Main St., Ste. 325, Akron, Ohio 44311 OR by fax to 1-330-535-2253.
I hereby authorize VANTAGE AGING, hereinafter called COMPANY, to initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit entries in error to my Checking OR Savings account (select one) indicated below and the Financial Institution named below, hereinafter called DEPOSITORY, to credit and/or debit the same such account.
Financial Institution (Depository) Name: *

City: State: Zip:

Total Check      Partial Check Amount: $

Routing Number:   *   Account Number:   *
This authority is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.
Name(s) on Account: *
Last 4 digits of Social Security #(s):
If you don't have touchscreen you can use your mouse to sign by holding down left key and drawing inside signature box.
Signature*
Upload Voided Check or letter from the bank below
File Upload

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If you don't have touchscreen you can use your mouse to sign by holding down left key and drawing inside signature box.

Upload Voided Check or letter from the bank below