Warning: This is a preview of the iForm only. You cannot submit answers.

DIRECT DEPOSIT ENROLLMENT

First Name:
Last Name:
Social Security #:
--
Any changes will overwrite saved masked data
Company Name:

 

Account Information:

If depositing to a savings account, ask your bank to give you the Routing/Transit Number for your account. It isn't always the same as the number on a savings deposit slip. This will help ensure that you are paid correctly. The last item must be for the remaining amount owed to you. Make sure to indicate what kind of account, along with amount to be deposited, if less than your total net paycheck.

 

Bank Name:
City:
State:
Routing/Transit #:
Account #:
Deposit:
$   or    Entire/Remaining Net Amount   or   %
Checking     Savings    Other

 

Employee Authorization:
I hereby authorize my employer to deposit any amounts owed me by initiating credit entries to my account at the financial institution(s) (hereinafter "Bank") indicated on this form. Further, I authorize Bank to accept and to credit any credit entries indicated by my employer to my account. In the event that my employer deposits funds erroneously into my account, I authorize my employer to debit my account for an amount not to exceed the original amount of the erroneous credit.  I agree that direct deposit transactions I authorize comply with all applicable law. My signature below indicates that I am agreeing that I am either the accountholder or have the authority of the accountholder to authorize my employer to make direct deposits into the named account.

This authorization is to remain in full force and effect until my employer and Bank have received written notice from me of its termination in such time and in such manner as to afford my employer and Bank reasonable opportunity to act on it.
Employee's Signature
 
(checking the checkbox above is equivalent to a handwritten signature)
Payroll Manager Authorization:
Payroll Manager Name:
Payroll Manager's Signature
(checking the checkbox above is equivalent to a handwritten signature)