Authorization For Direct Deposit

User Manual: Authorization-for-Direct-Deposit

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AUTHORIZATION FOR DIRECT DEPOSIT
***EMPLOYEES ARE RESPONSIBLE FOR NOTIFYING THEIR F1NANCIAL INSTIT UTION OF DIRECT
DEPOSIT FROM EMPLOYER.
PART1: COMPLETE ALL ITEMS
1. ACTION TO BE TAKEN
(CheckOne)_begin direct deposit_stop direct deposit_change financial institution_change account number
2. EMPLOYEE NAME
3. SOCIAL SECURITY NUMBER

4. DEPARTMENT
5. EMPLOYEENUMBER

6.TELEPHONE NUMBER

PART2: FINANCIAL INSTITUTION INFORMATION
7. TYPE OF ACCOUNT

CHECKING ACCOUNT NUMBER (attach a voided check)
SAVINGS ACCOUNT NUMBER (attach a bank memo)

8. FINANCIAL INSTITUITION NAME
ADDRESS

CITY/STATE

ZIP

PHONE NUMBER
9. FINANCIAL INSTITUTION ROUTING NUMBER-___ ___ ___ ___ ___ ___ ___ ___ ___
(obtained from your attached voided check information or from your financial institution for savings deposits)
AUTHORIZATION
Unless otherwise indicated above, I hereby authorize and request
Herein after referred to a EMPLOYER, to direct the net amount of my periodic pay for crediting to my account indicated at the
Financial Institution designated above, and I further authorize the Financial Institution to credit the same to such account
without responsibility for correctness of such amount.
This authorization will remain in effect until I initiate the required stop action in such time and in such manner as to allow
my employer a reasonable opportunity to act upon it. Furthermore, I understand that termination of employment with my
EMPLOYER shall constitute sufficient authorization to terminate this agreement.
I agree to notify my EMPLOYER if I wish to change the designated Financial Institution or account to which my net pay is to be
deposited, 30 days prior to the effective date of such change. I understand that failure to do so may delay the receipt of my net
pay.
Signature of Employee

Date

TO BE COMPLETED BY PERSONNEL DEPARTMENT
Date received

lnput Date

Date Processed

Effective Date of Direct Deposit
Source Exif Data: 
File Type                       : PDF
File Type Extension             : pdf
MIME Type                       : application/pdf
PDF Version                     : 1.5
Linearized                      : No
Page Count                      : 1
Language                        : en-US
Tagged PDF                      : Yes
Author                          : Cindy
Creator                         : Microsoft® Word 2013
Create Date                     : 2014:06:11 16:18:48-04:00
Modify Date                     : 2014:06:11 16:18:48-04:00
Producer                        : Microsoft® Word 2013
EXIF Metadata provided by EXIF.tools

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