Direct Deposit Authorization Form

Employee ID Number: ___________________________________

Employee Name: ________________________________________

I hereby authorize ______________________________ hereinafter called Company, to initiate credit and, if necessary, debit entries for adjustments to my:

Checking #1 ______________ __________________ Amount _____
Routing # (9 digits) Account # (4-17 digits)


Checking #2 ______________ __________________ Amount _____
Routing # (9 digits) Account # (4-17 digits)

Savings #1 ______________ __________________ Amount ______
Routing # (9 digits) Account # (4-17 digits)

Savings #2 ______________ __________________ Amount ______
Routing # (9 digits) Account # (4-17 digits)


Bank/Financial Institution____________________________________

Bank/Financial Institution Phone#______________________________
This agreement is to remain in effect until Company has received written notification from me of its termination in such time to afford Company and Depository a reasonable opportunity to act on it.

 

Signed _________________________ Date ____________________

Please attach to this agreement:

  • A check for checking account information
  • A deposit slip for savings account information