Payroll Direct Deposit Authorization
Payroll Direct Deposit Authorization Employee Name:
Social Security Number:
l l
You can have up to 6 accounts set up for direct deposit. [ ] Add new account [ ] Replace existing account [ ] Inactivate existing account [ ] Change existing amount [ ] Checking [ ] Savings
Bank Routing # (9-‐digits):
Bank Account #:
Write “Full” or Enter Partial Dollar Amount:
Bank Name:
$
[ ] Add new account [ ] Replace existing account [ ] Inactivate existing account [ ] Change existing amount [ ] Checking [ ] Savings
Bank Name:
Bank Routing # (9-‐digits):
Bank Account #:
Write “Full” or Enter Partial Dollar Amount:
$
[ ] Add new account [ ] Replace existing account [ ] Inactivate existing account [ ] Change existing amount [ ] Checking [ ] Savings
Bank Name:
Bank Routing # (9-‐digits):
Bank Account #:
Write “Full” or Enter Partial Dollar Amount:
$
I am voluntarily choosing to have my funds electronically deposited to the allocated accounts listed above. If funds that I am not entitled to are deposited into my account, inadvertently, I authorize the employer to retrieve the funds. I release the employer of any liability that might result from having the money electronically deposited or retrieved from my account. I understand that my deposit may not be credited to my account until 5:00 p.m. on the pay date indicated on the check voucher. I also understand that my final paycheck, upon separation of employment will NOT be directly deposited. I understand that it is my responsibility to provide you with the correct account and bank information. Incorrect data could delay the processing of my pay. I also understand that the Employer is not responsible if I write checks or make withdrawals from my account – BEFORE verifying that the funds are in my account.
Signature:
Date:
YOU MUST INCLUDE ONE OF THE FOLLOWING:
[ ] CHECKING ACCOUNT -‐ You must attach a VOIDED CHECK with your name and account information pre-‐printed on the check; or supply us with Documentation from the Bank with your Name, Account Number and the Banks TBA/ABA Routing Number. [ ] SAVINGS ACCOUNT -‐ You must provide us DOCUMENTATION FROM THE BANK that reflects your pre-‐printed Name, Account Number and the Banks TBA/ABA Routing Number.
Revised: 06/22/2012
Social Security Number:
l l
You can have up to 6 accounts set up for direct deposit. [ ] Add new account [ ] Replace existing account [ ] Inactivate existing account [ ] Change existing amount [ ] Checking [ ] Savings
Bank Routing # (9-‐digits):
Bank Account #:
Write “Full” or Enter Partial Dollar Amount:
Bank Name:
$
[ ] Add new account [ ] Replace existing account [ ] Inactivate existing account [ ] Change existing amount [ ] Checking [ ] Savings
Bank Name:
Bank Routing # (9-‐digits):
Bank Account #:
Write “Full” or Enter Partial Dollar Amount:
$
[ ] Add new account [ ] Replace existing account [ ] Inactivate existing account [ ] Change existing amount [ ] Checking [ ] Savings
Bank Name:
Bank Routing # (9-‐digits):
Bank Account #:
Write “Full” or Enter Partial Dollar Amount:
$
I am voluntarily choosing to have my funds electronically deposited to the allocated accounts listed above. If funds that I am not entitled to are deposited into my account, inadvertently, I authorize the employer to retrieve the funds. I release the employer of any liability that might result from having the money electronically deposited or retrieved from my account. I understand that my deposit may not be credited to my account until 5:00 p.m. on the pay date indicated on the check voucher. I also understand that my final paycheck, upon separation of employment will NOT be directly deposited. I understand that it is my responsibility to provide you with the correct account and bank information. Incorrect data could delay the processing of my pay. I also understand that the Employer is not responsible if I write checks or make withdrawals from my account – BEFORE verifying that the funds are in my account.
Signature:
Date:
YOU MUST INCLUDE ONE OF THE FOLLOWING:
[ ] CHECKING ACCOUNT -‐ You must attach a VOIDED CHECK with your name and account information pre-‐printed on the check; or supply us with Documentation from the Bank with your Name, Account Number and the Banks TBA/ABA Routing Number. [ ] SAVINGS ACCOUNT -‐ You must provide us DOCUMENTATION FROM THE BANK that reflects your pre-‐printed Name, Account Number and the Banks TBA/ABA Routing Number.
Revised: 06/22/2012
